Refusal Of Treatment and/or Transportation
This EMS unit was dispatched to this location for a report of ___.
Upon arrival, identified this person who, after a full assessment and offer of transport to a hospital has refused such transportation. EMS personnel have offered transport no less than three times.
- The chief complaint was ___.
- The general appearance is healthy and without severe disability.
- The level of consciousness is alert.
- The history of present illness is ___.
- The past medical history includes ___.
- A physical examination reveals no abnormalities.
- Vital signs were assessed as listed in this report.
- EMS was called by ___.
- The patient reports they are refusing transportation because they feel they no longer need ambulance transportation and can seek medical care on their own.
- EMS personnel have offered transport a minimum of three distinct times.
- The patient denies the consumption of significant amounts of alcohol or other substances of abuse, and does not appear to be acutely intoxicated or under the influence of any substance, in the opinion of this provider. Gait is steady, neurological response appears normal, there is no slurred speech.
- The patient denies acute behavioral disorders and appears to have normal behavior without bizarre actions.
- This patient appears to be competent to make an informed decision regarding medical care at this time.
- The risk of refusing medical care and transportation, including worsening of symptoms, missed injuries and possible death were explained clearly to the patient.
- The limitations of this EMS crew, lack of physician level assessment and lack of advanced assessment tools was explained clearly to the patient.
- The patient was advised to seek medical attention or dial 911 by telephone if they change their mind and wish transport or have a return or worsening of symptoms.
- The patient was asked to sign the usual refusal form
- The patient’s signature was witnessed, and the witness signed this form.