Refusals

[Bieber]

You are correct with your thinking, but to really make sure everything is documented, don't just use the 'is this a patient' idea. Document any contact whether patient or not, complaint of not, arrived scene or not. With this understanding, the paperwork stinks, but better than your butt.

We do document, even disregards. It's just more minimal than if we were doing a full patient assessment and report.

[paraloco]

Unless there is nobody home, fled the scene on foot(happens all the time at wrecks), or canceled by dispatch, I have to get a refusal. Had a call recently where a resident was vacuuming and inadvertently hit her lifecall button. I had to get a refusal. Had another one where the resident looked like death warmed over. She had advanced cancer and had just come home from chemo. She said she didn't call us, and had no idea who did. She refused all services and I got a refusal signed. We cleared, got another call, and about 5 minutes later another truck went to the house 2 doors down from her. The caller had given the wrong address to dispatch. Documentation saved my butt because their patient was in really bad shape, and they thought we left them there.

[Bieber]

Unless there is nobody home, fled the scene on foot(happens all the time at wrecks), or canceled by dispatch, I have to get a refusal. Had a call recently where a resident was vacuuming and inadvertently hit her lifecall button. I had to get a refusal. Had another one where the resident looked like death warmed over. She had advanced cancer and had just come home from chemo. She said she didn't call us, and had no idea who did. She refused all services and I got a refusal signed. We cleared, got another call, and about 5 minutes later another truck went to the house 2 doors down from her. The caller had given the wrong address to dispatch. Documentation saved my butt because their patient was in really bad shape, and they thought we left them there.

What do you put as the chief complaint on your chart? Or do you just leave it blank? Also, do you have to complete and fill out a full patient assessment? Get a full set of vital signs?

Edited February 1, 2011 by Bieber

[FireMedic65]

This is why you document everything in detail. I used to write at least a page for a narrative for basic IFT calls. The same for lift assist and being canceled. I was "spoken with" a few times from the higher ups that it was not needed and to stop doing it. I disagreed and eventually quit that job because they seemed like they didn't care.

Regardless, the patient always holds the right to refuse care, treatment and transport (except of course they are mentally unable to make their own decisions).

As for your partner not doing paperwork on lift assists, they are putting themselves in a bad spot for liability. Every call should have documented proof and be well written like you actually care about your job and the patient.

[NYCEMS9115]

No Policy regarding RMA? That doesn't make sense. Ask your boss; ask the EMS Regional Council. You have to let your Supervisor(s) know about this. Your revealing that its been on several occasions your partner leaves the scene w/o documenting or assessing.

I know its a State violation; I don't need to know your State. Every State has Protocols regarding RMAs. An assessment and interview must be done at the minimum; signatures with a witness are a must .

This doesn't make any sense. Your company has Policies and your EMS Region has Protocols. Ask someone. You obviously need postive leadership. Someone(s) must guide you. Don't be insulted; you don't know. This forum really can't help; go to your bosses and the EMS Region... Good luck. All the best...

FireMedic65 31 January 2011 at 11:37 PM; Posted "This is why you document everything in detail. I used to write at least a page for a narrative for basic IFT calls. The same for lift assist and being canceled. I was "spoken with" a few times from the higher ups that it was not needed and to stop doing it. I disagreed and eventually quit that job because they seemed like they didn't care."

I'm all for documentation but cancellation prior to arrival; need for thorough documentation. What else can you write? Other than, "cancelled by dispatcher enroute to location." You can write no patient contact made; if you like. Is there anything else you can write for the cancelled call before making patient contact? Thanks. All the best...

Just remember. Its easier to defend a fully documented PCR than to defend no paperwork generated. When and if the law process comes into picture; you'll have aged several years & you'll never remember this call.

My rule is and it goes above and beyond any State Protocol. If I make patient or person contact and the person/patient doesn't want to go to the Hospital; I'll document the findings, the events of the call, and get the person/patient to sign the refusal. Regardless of why I'm there (Medic Alert accidental trip, unable to use equipment, changed mind, wanted someone to come to make something to eat, etc). It will protect you in the long run. Lawyers are very go at manipulating the true; they know your profession better than you; & they are very good researchers. Good luck. All the best...

[Chief1C]

CC: Patient has no complaint, requested lift assist, etc., only.

[NYCEMS9115]

How did the patient ended up needing a lift assist? Did she try to go number one or two but lost her footing and she couldn't get up off the floor. I mean you're better off to document and have the patient sign the RMA. She may c/o pain later and no PCR or RMA was generated; the lawyers will have a field day with this. Its better to just secure the RMA than to mark it as an unnecessary for EMS. I'm not saying to document a book but document the events and findings with remarks of patient's adament refusal of going to ER; get them to sign and get a witness. What's the big deal? 5minutes added to your time. I'm just saying.

Ex. U/A fd 50 y/o F with PD onscene, NAD, no complaints. Sts she's embarrassed that EMS was there. She sts she was sleeping; may have rolled over and hit her medic alert. Pt speaks full sentences; A/0x3; answers questions appropriately. Pt offered a transport to the ER but declined; sts she is fine & wants to go back to bed. Pt made aware to call 911; if any problems should arise. RMA signed by patient & witnessed by PO Smith, Daecy PD.

4c6 02 February 2011 - 11:35 PM "CC: Patient has no complaint, requested lift assist, etc., only."

That doesn't make sense. The person technically has a complaint. Requested lift assist; isn't that a complaint? Well more like something went wrong for the person, called for 911, & the person needs your help to rectify it. I think that's what EMS Providers do for a living; I think that is so.

If you just told me that the person; had no complaints and just needed you to pick them up; it was just a lift assist. I'm gonna ask you; how did the person end up on the floor? 5 years down the line with no paperwork; you're not going to remember any details to this call. So a RMA with a generated PCR will be your only protection. The person refused treatment & transport to the ER. Its not your problem. Any Lawyer will be able to litigate this case on the person's behalf. As in, they be-halfing some money from the company for negligence. Just throwing that out there to ponder on... All the best...

[fakingpatience]

I hadn't really thought about what if the person gets hurt/ sick later, and someone tries to say the ambulance crew was negligent the first time we were there for a lift assist, and we have no paperwork to back up our story. Definitely makes me more strongly want to do correct refusal paperwork.

NYCEMS: My supervisors know that people leave lift assist calls without documenting names and such, everyone does it at my company, including many supervisors if they are working on the ambulance. You could say it is in the "culture" of the company to, for lift assists, simply document either "lift assist only, no info, no signature" or "no pt contact". I think part of this stems from calls that we run with the fire department that end up being refusals, the fd does all the paperwork, so my coworkers get very used to not doing refusal paperwork. It becomes an issue when it is an "ambulance only."

I guess my next hurdle is going to be having the courage to tell my partners (not talking about one specific, I work with different people every shift, no permanent partner ) that I want to do the proper documentation on all those refusals...

[NYCEMS9115]

I'm not saying its wrong or right. Just something to think about. It will take for something bad to happen on these types of calls, for Protocols to change. It is, what it is. We are a reactive society. Something bad has to happen before we change. I'm okay with that. I'm just putting my opiniom out there and sharing what I do. All the best....

[usmc_chris]

Thorough documentation is absolutely essential. In my system, even visually "looking" at a patient is considered "patient contact." For example, if I walk into a scene, and another unit is on scene in the process of obtaining a signed release (All agencies that provide EMS are required to complete a full PCR on every run, regardless of whether they are BLS first response, FD based, or whatever) and they "cancel" me at the door, I am still required to at the very least complete a "visual" assessment.

Ex: Dispatched for NAEMD 17A1 fall, caller requesting lift assist only. Arrived on scene with FD Engine XXX. Entered residence, arrived to find approximately 60 y/o male pt, appears conscious and alert. FD unit state that pt has no complaints, had slipped from his chair and they picked him back up. They state that pt is adamantly refusing care, denies any head/neck/back pain, they have completed full assessment and are in the process of obtaining a signed refusal from the pt. FD state that pt has denied any chest pain/pressure, shortness of breath, or loss of consciousness. No need for full ALS assessment at this time. Pt is in no apparent distress, skin appears normal, is speaking in full sentences to FD crew with no apparent exertion. FD states that ambulance can cancel as they will complete signed refusal. Returned to service without further pt contact.

There are plenty of people out there that would pretend they didn't make it in the door and document this as "cancelled on scene by FD, no patient contact." However this isn't acceptable. Furthermore, assuming that the first unit on scene was a BLS unit (we do have one agency that we respond with that provides ALS FR), if the call came in as a NAEMD C, D, or E, the ALS provider has to do a full assessment and complete any refusal documentation, regardless of what the FD unit states. The level of documentation is annoying sometimes, but in the end, it will CYA. Society today is far too litigious to risk not fully documenting any encounter with any person.