Documenting patient refusals

Patient morbidity and mortality, subsequent to either patient- or provider-initiated refusals, are noteworthy. It has been estimated that hospital admission is twice as likely after prehospital providers refuse a patient transportation to the hospital. In one particular study group, prehospital-provider refusal of transportation, as opposed to patient refusal of transportation, accounted for 73% of the post-refusal hospital admissions. Provider-initiated refusals are tantamount to a time bomb. There are very few justifiable provider-initiated refusals of treatment or transportation. If the call is of a non-emergency nature, the decision not to treat or transport should be a mutual agreement between the patient and provider. Consult with the online medical director for guidance as needed. Document the physician's name, consulting facility and medical direction. As with every patient encounter, a legally defensible runsheet should be completed. Should you write a report if your services are "not needed," or if you are canceled en route to the call? For your protection, a report archiving every run should be documented. If your services are canceled en route, note the canceling authority and time of cancellation. If your services are canceled at the scene, document the canceling authority, time of cancellation and the circumstance. It is important to specifically document that "no patient contacts were made." When patient contact is made, a patient-provider relationship is established, thereby redefining your duty to the patient. Protect yourself, your crew members, your chain of command, your jurisdiction and your agency by writing a legally defensible informed refusal report. According to one source, "Every negligence case in the last 30 years has been decided on its documentation." If it wasn't written down, it wasn't done. Be safe, and document safely.