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Category: Other

Refusal of Service Documentation – patient walking away

Question #: 455

Question:


How do we properly fill out a 72 for a patient who may or may not be cooperative with EMS, who walks away swearing/agitated, who refuses treatment/transport, refuses to speak with EMS and refuses to sign the 72. When you complete the patient in capacity portion, you are forced to check "no" for the patient knowing the risks involved. How would you like paramedics to properly document a scenario as such?

Answer:


You can document that the patient did not consent to a physical assessment. In addition, you should document your visual observations and visual assessment of the patient’s apparent condition. What queues or risk factors did you observe during your interaction with the patient? Document all of your visual assessment to add credence to your patient interaction.
Things to document could include in the physical exam general appearance, estimated respiratory rate, comment on their: airway, breathing, speech, gate, visible trauma, bleeding, general demeanor, pupils, etc. Immediately on patient contact, conduct the primary survey by noting the patient’s the degree of distress and CTAS (consistent with the BLS PCS general measure).
It’s up to you as the provider to convey the concerns you observe to the patient, and it’s the patient’s responsibility to do with that information as they see fit. They have the right to refuse assessment, treatment, and transport. Document the occurrence, what your observed, what the patient said and did, and document your concerns.

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