Special considerations of documentation

A patient refusal is when a patient chooses to not allow EMS to transport them to the hospital. As with with anything else, there is a bit of a gray area in documentation of a refusal.  There are several good reasons why a refusal is a little gray.  

• Refusals are often used to document calls where transport is clearly not indicated.  In the interest of protecting the agency, the crew or supervisor has the patient sign a refusal form with the belief that a signed refusal will shield them from any liability (really not true).  
• Having executed one of these non-transport call refusals a dozen times undermines the importance of an honest refusal.  The crew thinks, “well, if the guy who cut himself while shaving only needed to sign a refusal, then why doesn’t’ this guy who is clearing suffering from a myocardial infarction?”  The crew knows that an honest refusal is a big deal, but due to the lack of consistency in the definition of a refusal, experiences anxiety.  The anxiety comes from the fact that all that was required for the ‘non transport’ refusal was a signature on a refusal form, while the honest refusal is a potentially nasty situation that requires a level of completeness and thoroughness not required in any other patient care situation.  
• It is probably not feasible to document all refusals (no transport required and an honest refusal) with the same attention to detail as an honest refusal.  So the situation gets more vague because now you have to choose how much detail you need to document for the non-transport situation and the actual refusal situation.  

Since every ambulance service views non-transport situations and refusals differently, from this point on the term patient refusal will be used to describe a situation where a patient refuses medical care, evaluation, or transport when the care, evaluation, and/or transport is actually medically necessary.  When a patient refuses medical care, the EMT or Paramedic must show in the report the process undergone to reach that conclusion.  The patient care report narrative must include quotations or statements by others and signatures of witness(es) to the event (according to local protocol).  The patient care report must include:

• The EMT or Paramedic’s advice to the patient and the advice rendered by medical direction by telephone or radio (if possible). The patient must understand the severity of the injury and risks associated with refusing transport.
• Some sort of statement that indicates the patient understood the advice given by the EMS crew.
• If the patient is not conscious, alert, and oriented (minimally to time, place, and date) then the patient is clearly in no condition to sign a refusal.  
• The EMS crew must address the competency and alertness of the patient.  UNDERAGE, MENTALLY, OR EMOTIONALLY INCOMPETENT PEOPLE ARE NOT CAPABLE OF MAKING MEDICAL DECISIONS FOR THEMSELVES.  This includes minors, the mentally challenged or even people who are emotionally disturbed (even temporarily).  Further, the patient must be classified (as defined by OCGA – Section 31-9-2 as a person authorized to consent (if a person can consent, they can also refuse).

O.C.G.A. § 31-9-2 

GEORGIA CODE
Copyright 2006 by The State of Georgia
All rights reserved.

TITLE 31.  HEALTH  
CHAPTER 9.  CONSENT FOR SURGICAL OR MEDICAL TREATMENT 

O.C.G.A. § 31-9-2  (2006)

§ 31-9-2.  Persons authorized to consent to surgical or medical treatment


   (a) In addition to such other persons as may be authorized and empowered, any one of the following persons is authorized and empowered to consent, either orally or otherwise, to any surgical or medical treatment or procedures not prohibited by law which may be suggested, recommended, prescribed, or directed by a duly licensed physician:

   (1) Any adult, for himself, whether by living will or otherwise;

   (1.1) Any person authorized to give such consent for the adult under a health care agency complying with Chapter 36 of Title 31, the "Durable Power of Attorney for Health Care Act";

   (2) In the absence or unavailability of a living spouse, any parent, whether an adult or a minor, for his minor child;

   (3) Any married person, whether an adult or a minor, for himself and for his spouse;

   (4) Any person temporarily standing in loco parentis, whether formally serving or not, for the minor under his care; and any guardian, for his ward;

   (5) Any female, regardless of age or marital status, for herself when given in connection with pregnancy, or the prevention thereof, or childbirth;

   (6) Upon the inability of any adult to consent for himself and in the absence of any person to consent under paragraphs (2) through (5) of this subsection, the following persons in the following order of priority:

      (A) Any adult child for his parents;

      (B) Any parent for his adult child;

      (C) Any adult for his brother or sister; or

      (D) Any grandparent for his grandchild.

(b) Any person authorized and empowered to consent under subsection (a) of this Code section shall, after being informed of the provisions of this Code section, act in good faith to consent to surgical or medical treatment or procedures which the patient would have wanted had the patient understood the circumstances under which such treatment or procedures are provided.

(c) For purposes of this Code section, "inability of any adult to consent for himself" shall mean a determination in the medical record by a licensed physician after the physician has personally examined the adult that the adult "lacks sufficient understanding or capacity to make significant responsible decisions" regarding his medical treatment or the ability to communicate by any means such decisions.

The object in documenting a refusal is to prove all four elements (advice, understanding, alertness, competency) it could be argued that the patient was abandoned.  A defendable (legally) refusal is what the EMS crew will want to have submitted in the event the patient has a poor outcome resulting in public outcry. Additionally, if these questions were answered the discovery process can go much smoother:

• Does the patient possess a valid drivers license?  A minimal amount of screening occurs before the issuance of a driver’s license.
• Does the patient appear to have a job that requires a responsible person?  This sounds judgmental, but if your patient has a job that requires a certain amount of education, certification, licensure then they may normally be competent.
• Does your patient give the indication that they normally make their own medical decisions?
• Does your patient give a valid reason why he/she does not wish to be treated/evaluated/transported to the hospital?  The patient shouldn’t win you any points if he/she doesn’t want to go to the hospital for some emotional or imagined reason.

Patient refusals can also come in various flavors:

• The patient refuses all care, including an assessment (this would only be indicated if the patient either obviously has an injury or confessed to you that he/she has a complaint of some sort). – This is particularly dangerous to you as the patient could have an injury or illness, but gives you the opportunity to document the call as a ‘no patient’.  
• The patient refuses transport – This is the scenario that nearly everybody in the EMS business will be familiar with.  Don’t forget that just because the patient doesn’t’ want to be transported doesn’t mean that you still can’t treat them.  Good example, let’s say a patient is having an asthma attack but refuses transport, consider administering a breathing treatment before you leave.  At least you did something for them in the event they succumb to their affliction.
• The patient refuses some element of treatment (usually something painful like an IV or spinal immobilization) but allows you to transport.  

Document decisions/ events where care and transportation were not needed

Anytime a call has been dispatched (and/or a case number assigned), a patient care report is completed as a record of the incident.  There are times when you will be dispatched to a call and nobody will be there.  These calls require documentation for all the same reasons already discussed.  

Canceled en route

If canceled en route, note canceling authority and the time.  When documenting this call, be sure to include a description of the type of call EMS was dispatched to (motor vehicle accident, domestic dispute, chest pain, etc.).  In the narrative, it should be noted which agency canceled the unit (like PD or other First Responder). 

EMS dispatched to a person down unconscious and not breathing.  While en route, a PD unit advised that the patient was DOA. 

Canceled at scene

If canceled at scene, note canceling authority and special circumstances (e.g., “On scene officer reported no injuries and asked us to leave the scene – no patient contacts made”).  

EMS dispatched to a person down complaining of nausea and vomiting.  Upon arrival, Engine 18 cancelled EMS advising family was taking the patient to the hospital.

No one at scene

What if EMS gets there and nobody is found?  The documentation should describe the type of incident you were dispatched to in the first place. Be sure that the documentation reflects your attempts to find the patient(s).

EMS dispatched to a motor vehicle accident at the intersection of two county roads.  Upon arrival, neither complainants nor vehicles were found.

No patient at the scene of an actual incident

Keep in mind that anybody that has a complaint (no matter how small or insignificant) is a patient that requires assessment and treatment (even if they don’t technically require transport).  So in order for an incident to have occurred and no body be injured, the following must be true:

• The mechanism of injury must be insignificant.  A good way to view the significance of a mechanism of injury is to determine if the incident meets any of the trauma triage criteria (the mechanism criteria itself implies that if a patient were to actually meet those criteria, they are injured until proven otherwise in a trauma center).
• Nobody on the scene should have a complaint or a visible wound associated with the incident.  If you can see the patient bleeding, yet they say they are okay, an assessment is indicated.  If you see the patient bleeding and the patient does not want an assessment, then a patient refusal should be signed.

EMS dispatched to a motor vehicle accident at the intersection of two county roads.  Upon arrival, three vehicles were found along the side of the road.  Three parties were involved, all of which denied any complaint and no obvious injuries were seen among the three.  The mechanism is a low speed collision to the front and rear of the three cars not meeting Trauma Triage Mechanism Criteria.  

Documentation in mass casualty situations

In unusual circumstances, comprehensive documentation has to wait until after mass casualties are triaged and transported.  The EMS crew should know and follow local procedures for documentation of mass casualty situations.  Complete documentation is often completed once all of the patients have been transported off the scene.  Once the call is over, the EMS crew could easily have to sit down and write 10 or 15 patient care reports.  

Consequences of errors, omissions, and inappropriate documentation

An incomplete, inaccurate, or illegible report may cause subsequent caregivers to provide inappropriate care to a patient.  There are some situations where the patient care report that was given to the nurse at the hospital will be referred to over and over (like the case of an unconscious patient, especially with serious trauma).   Additionally, a lawyer considering the merits of an impending lawsuit can be dissuaded from a case when the documentation is clear and self explanatory.

How To Make Corrections or Amendments

Back when EMS reports were mainly done on paper, EMS personnel were instructed to draw a line through an incorrect word and initial above the line. If a detail was forgotten while documenting the incident, an amendment form could be used to document the missing information.