ECU/BSOM/EM
Run #:____________________
Pitt County Emergency Medical Services
Supplemental Report for Patient Refusal of Transport and/or Treatment
Patient’s Name: __________________________________________________________________________________________ Age: _________
Complete the entire assessment below (if allowed). A check mark in any single shaded area requires contact with medical direction.
Patient’s Age?
< 2 yoa
_____YES
_____NO
2– 17 yoa without parent/guardian at scene
_____YES
_____NO
> 65 yoa
_____YES
_____NO
Pulse?
< 50 or > 120
_____YES
_____NO
Systolic BP?
< 90 or > 200
_____YES
_____NO
Diastolic BP?
> 120
_____YES
_____NO
Respirations?
< 8 or > 24
_____YES
_____NO
Chest Pain?
_____YES
_____NO
S.O.B.?
_____YES
_____NO
Hypoglycemic and on any oral hypoglycemic agent?
_____YES
_____NO
Altered mental status and/or intoxication (alcohol or other drugs)?
_____YES
_____NO
NOT alert and oriented?
_____YES
_____NO
NOT oriented to: Person: ___
Place: ___
Time: ___
Situation: ___
Physician giving medical direction? __________________________________________
PATIENT REFUSAL
The EMT has recommended that either you or the patient (should you be the guardian):
__ have your blood pressure and other vital signs measured.
__ receive oxygen.
__ receive an IV.
__ be placed on a backboard with a neck collar.
__ receive a complete physical exam.
__ be transported to the hospital by
EMS.
__ receive medication: _____________________
__ Other: __________________________________________________________
Universal Patient Instructions:
1. You have not by evaluated by a doctor.
2. You have not received a complete medical evaluation. You should contact or see your doctor immediately.
3. If at any time after you have taken any medication, you have trouble breathing, start wheezing, get hives or a rash, or have any
unexpected reaction, call “9-1-1” immediately.
4. If your symptoms worsen at any time, you should see your doctor; go to the hospital or call “9-1-1”.
Motor Vehicle Crash Instructions:
1. Please contact your doctor if any one of the following signs or symptoms develop:
Increased pain to any body area Swelling, numbness or tingling Drowsiness or increased irritability
Nausea or vomiting
Persistent or bad headache
Vision problems
Speech or hearing difficulty
Weakness
Loss of feeling in arms or legs
Difficulty walking
Twitching or convulsions
Confusion
Neck or back pain
Unequal pupils
Loss of consciousness
Loss of memory
Bleeding or discharge from the nose or ears
2. Awaken the patient every 2 hrs. for the next 12 hrs. to make sure he/she can be easily aroused and can answer simple questions.
3. Do not take any sedatives, alcohol or pain medications without first checking with your doctor. Check with your doctor if you are taking
aspirin regularly.
4. Apply cold to any tender/painful area.
5. If the EMT has recommended, or you feel you should be evaluated for stitches, then you should seek medical attention as soon as
possible and within 6 hrs. of the injury.
6. Clean any wounds and keep them clean. Wash with soap and water 2-3 times/day. Do not soak.
7. Apply a small amount of antibiotic ointment after washing. Do not apply any ointment if you will be seeking immediate medical
attention.
8. Cover the wound with sterile gauze dressings. Adhesive bandages maintains moisture and increase the risk of infection.
9. Provided that you are not allergic, ibuprofen or acetaminophen may be taken as directed for pain or discomfort. Avoid taking aspirin.
Check with your doctor if you are taking aspirin regularly.
10. Contact your doctor if it has been more than 5 years since your last tetanus shot or if you are uncertain. If required, the tetanus shot
should be given within 24 hrs. of the injury.
Low Blood Sugar Instructions:
You have had a period of unconsciousness or altered level of consciousness that may have been caused by a low level of sugar and may be related to
your diagnosed condition of diabetes. The EMT may have administered medication or sugar to improve your condition, but this improvement is often
only temporary. It is important to have regular check-ups so that your doctor can help you control your blood sugar level, which can be controlled with
medication and proper diet.
Today your blood sugar was ________ before and ________ after you were given medications.
You have decided not to be transported by ambulance to a medical facility following a probable low blood sugar episode. Please contact your
doctor as soon as possible to notify him/her of this episode and if the frequency or severity of your low blood sugar level episodes increase.
1. Take your medicine exactly as prescribed and eat right away. The sugar/medicine you were given is short acting.
2. Wear a medic alert tag at all times.
3. Have a responsible person wake you every 2-hours for the next 12-hours.
4. Check your blood sugar again in 1-2 hours to make sure it is okay and then test your urine or blood sugar as directed.
5. If you feel like your blood sugar is getting low, test it and eat as directed.
6. Stay with a competent caregiver, and teach family members and others close by how to help when your blood sugar becomes too low.
7. Discuss with your doctor whether there should be any restrictions on your job or activities.
I refuse the _____ TREATMENT and/or _____ TRANSPORTATION that the EMT has recommended.
I understand that my refusal may result in serious injury or death to myself or the patient. I accept full responsibility for this decision. I assume all risks
and consequences resulting from my refusal of care. I will not hold the EMS provider organization, nor its officers, agents, employees or physicians
responsible for any outcomes that may occur to me or the patient. I acknowledge that I have had the opportunity to ask questions, if any, and that
they have been answered. My signature below attests that I understand what has been recommended and what the consequences may be due to my
refusal. I have read or been read and understand the instruction(s) noted above. I knowingly still refuse to receive medical treatment and/or
transportation that have been recommended by EMS.
______________________________________________ ________________________________________
Patient/Guardian Signature (Refused to sign _____)
Guardian’s Printed Name
__________________________________/__________________________________
Witness Signature
Witness’ Printed Name
_______/_____/___________
Date
___________________________________________
EMT’s Signature
Version: Pitt County 2012 EMS Protocols Form revision March 15, 2013
Appendix K
2013