How to write a well documented patient refusal report.
Introduction
 Recognize the potential for liability with regard to patient refusals.
Objective 2‐1 Define Duty to Act
 Duty to act:
 Refers to the EMS professionals legal obligation to act in accordance with established scope of practice and d
ith t bli h d f ti d standard of care.
 Duty to act begins with the dispatch of EMS to respond y
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and make patient contact.
 Duty to act extends to evaluating the patients capacity, competency, and right to self determination.
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Objective 2‐2
Objective 2
2 Define abandonment
 Abandonment:
 Termination of the EMS provider relationship prior to appropriate transfer of care.
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f f  If there is a failure to determine that the patient is able to refuse care then there is a breach in the duty to act y
resulting in abandonment.
Objective 2‐3
Objective 2
3 Define self determination
 By law patient’s have the right to self determination.  Self determination is defined as a persons right to make their own decisions without
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pressure or inappropriate influence.
 EMS must not violate the patient
EMS must not violate the patient’s right to self s right to self determination by acting against the patients will.
 Self determination is defined by consent.
 The ability to say yes or no to EMS.
Objective 2‐4
Objective 2
4
Define capacity
 Capacity is a persons legal authority or qualifications to make his or her own healthcare decisions.
 Usually the patient has the legal capacity to refuse U ll h i h h l l i f medical treatment if they are over the age of 18 (in most states).
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Objective 2‐5
Objective 2
5
Define competency
 Competency is defined as the ability to make medical decisions.
 This can only be accomplished by assessment of whether the:
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 Patient is alert and oriented
 Patient has the ability to comprehend what is being communicated.
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 Patient has the ability to understand the benefits of EMS treatment.
 Patient has the ability to understand the risks of refusing P ti t h th bilit t d t d th i k f f i treatment.
 Patient has the ability to make a decision based on EMS assessment.
assessment
Objective 2‐6
Identify the difference between types of
Identify the difference between types of consent
 Informed Consent:
 Is the agreement to accept or refuse medical treatment.
 Ability to accept or refuse is based upon:
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Patient has been educated:
 on injury/illness
 Treatment being proposed
 risk and benefits of treatment
 dangers associated with refusing treatment
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Objective 2‐6
Identify the difference between types of
Identify the difference between types of consent
 Implied Consent
 Consent for medical treatment that is assumed for a patient who is unable, by reason of illness or injury, to ti t h i bl b f ill
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t grant informed consent.
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Examples: unresponsive patient, or patient found in cardiac p
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arrest.
Objective 2‐6
Identify the difference between types of
Identify the difference between types of consent
 Involuntary consent
 Consent for medical treatment that is made on behalf of a patient by legal process.
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Example: a court appointed guardian for a person who is incapable of making medical decisions.
Objective 3‐1
Discuss the meaning of the AEIOU acronym
Discuss the meaning of the AEIOU acronym as it relates to patient refusal.
 Assessment
 Everything in EMS begins with assessment.
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The assessment of a patient who refuses or is undecided h
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requires a drastic change in the approach to patient assessment.
For patient refusal we first have to assess for the patient’s condition, the capacity and the competency of the patient. This can be done through the ABCD approach.
Objective 3‐1
Discuss the meaning of the AEIOU acronym
Discuss the meaning of the AEIOU acronym as it relates to patient refusal.
 A= Alert: Is the patient alert to person, place, time, and event?
 B = Behavior: Is the patient’s behavior appropriate?
B B h i I h i ’ b h i i
 C = Comprehension: Is the patient able to comprehend their condition and risks associated with refusal?
their condition, and risks associated with refusal?
 D = Decision: Is the patient legally qualified to make the decision to refuse?
Objective 3‐1
Discuss the meaning of the AEIOU acronym
Discuss the meaning of the AEIOU acronym as it relates to patient refusal.
 Educate
 Education will do more to turn around refusals than anything else.
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 When educating, avoid medical terminology that would not be understood by a lay person (i.e. M.I. vs. Heart y
yp
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attack, CVA vs. Stroke).
 Educate on the results of your assessment, possible medical diagnosis, and what treatment you can provide.
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Objective 3‐1
Discuss the meaning of the AEIOU acronym
Discuss the meaning of the AEIOU acronym as it relates to patient refusal.
 Inform
 The patient must be informed of the risks and consequences involved with refusing EMS services.
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 Risk statements should be specific to the assessment findings.
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“You are showing signs and symptoms of having a stroke. If you are not diagnosed and treated properly you risk permanent disability or death ”
permanent disability or death.
Objective 3‐1
Discuss the meaning of the AEIOU acronym
Discuss the meaning of the AEIOU acronym as it relates to patient refusal.
 Offer transport
 It is imperative to offer transport to the patient. If they refuse continue to offer at least three times.
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 If after three attempts the patient still refuses, you should avoid deferring your responsibility to the patient gy
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or family member (i.e. have your family drive you).
 Acceptable alternatives are:
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“You can call 911 back at any time.”
“If you develop symptoms or if your symptoms become worse you should dial 911 at once and an ambulance will come to pick you up.”
Objective 3‐1
Discuss the meaning of the AEIOU acronym
Discuss the meaning of the AEIOU acronym as it relates to patient refusal.
 Understand
 Despite EMS’s best efforts if the patient continues to refuse the provider must validate the understanding of f th id t lid t th d t di f the refusal.
 Review the refusal process with the patient.
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 Have the patient sign the refusal from, and have it witnessed by a third party (not an EMS provider).
 Also provide a patient instruction sheet if applicable.
If it wasn’tt written it didn
written it didn’tt If it wasn
happen.
 4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 4‐2 Identify the need for a standardized patient Id if h d f d di d i instruction form.
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4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
acronym as it relates to patient refusal
 The goal of refusal documentation is to limit liability.
 Documentation needs to prove that the duty to act was ffulfilled, prove the patient’s capacity and competency, lfill d h i ’ i d and prove the patient’s informed consent.
 This can be accomplished by using the CASE CLOSED acronym for bullet proof documentation of a refusal.
Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 C = Condition, Capacity, and Competency:
 This should include the patient’s “chief complaints” in the p
patient’s own words.
 Competency must be proven by assessing the patient’s neurological and mental status.
 Simply documenting that the patient was alert and oriented is not sufficient documentation.
 Things that should be documented are:
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Cognitive function
Signs of drug or alcohol use
Patient’s behavior
Speech pattern
Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 A = Assessment
 History of present illness or injury
 Past medical history
 Physical findings
 Vital signs
Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 S = Statements:
 Patient statements that were made in the refusal process should be documented.
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Understanding of their condition in their own words.
Understanding they are refusing care and the risks involved.
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Understand that by signing the refusal form they are taking the responsibility of the consequences involved.
Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 E = Educate
 Document the information provided to the patient and th the manner in which you validated the understanding.
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Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 C = Consequences
 Documentation must include that the patient was i f
informed of potential consequences of refusing care.
d f t ti l f f i Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 L = Limitations of EMS
 Documentation must include how the patient was i f
informed of the diagnostic and treatment limitations of d f th di
ti d t t
t li it ti
f EMS.
Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 O = Offer Transport
 Document the refusal of transport and the number of ti
times the patient refused your offer of transport.
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Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 S = Signature  The patient refusal form is a legal document and must b i
be signed by the patient.
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 Signatures that need to be present on the refusal form include:
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Patient or legal guardian
EMS Staff
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Appropriate witnesses
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Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 E = Educational Material
 Document any educational material given to the patient.
 This would include a patient instruction form.
 These sheets should be pertinent to patient’s condition. Examples are:
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Diabetics
Seizures
Asthmatics
Objective
4 1Discuss the meaning of the CASE CLOSED
4‐1Discuss the meaning of the CASE CLOSED acronym as it relates to patient refusal
 D = Dial 911
 Refusal documentation must always include that the patient or family was instructed to call EMS immediately ti t f il i t t d t ll EMS i
di t l if there is a change in the patient’s condition.
Conclusion
 Employing the simple techniques proposed in this presentation will go a long way to assure that patient refusals are legally defensible.
refusals are legally defensible