Termination of a
Provider/Patient
Relationship
Dona Ana
County
Release of
Liability
2-16-2011
Objectives
1.
2.
3.
4.
Understand the “why” and the process
behind the termination of a
provider/patient relationship
Understand and implement the changes
to approach and documentation
Establish standards for capacity,
documentation and supervision
Apply this policy to scenarios
The Why: Why are we changing
our current process?
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We have no clear policy on how to terminate a patient
relationship
Our system offers little guidance to our pre-hospital
personnel
It is necessary to establish and follow a standardized
approach to include the process and form
You have an obligation to the agency for which
you work
The Why: Where did this policy
come from?
Our policies, a combination of best
practices from other EMS Systems
across the country
 Changes were made to adapt to our
system.
 The policy and forms have gone through
legal and medical direction review

The Why: Review of
Abandonment, Negligence

The act of leaving a patient without
treatment or transportation without the
patient’s informed consent

Failure to use such care as a reasonably
prudent EMS provider would use in similar
circumstances
The Why: Reality Check
Most refusals are obtained for noneventful situations
 EMTs are not likely to recall the event or
patient years after the call
 Failure to document to serve as proof of
the events that day will be very damaging
to an EMT’s defense

The Why: Another reality check

Lack of documentation is
A response to increasing call volume
 Need for proper medical and legal
categorization of patients and non-patients

The Process: What has been
changed?
A countywide policy was created
 The “Refusal Form” has been revised –
now called the “Dona Ana County
Release of Liability Form”
 The cancellation form/documentation has
been revamped

The Process: Who is a patient?
A.
B.
A person consenting (informed or implied) to assessment
and/or treatment;
Any person having a current history, or perceived or observable
condition, of any of the following:
1. A physical or psychological complaint;
2. Altered level of consciousness;
3. Alcohol or drug use;
4. Medical history that has a potential to worsen or complicate
present condition;
5. A person presenting with an obvious injury;
6. A person suffering from a significant MOI, regardless of
injury; or
7. Any patient who has an ambulance summoned on their
behalf AND requires medical assessment and/or intervention.
The Process: You have a patient
relationship. Now what?

Consenting, competent adults who allow
assessment, treatment and transport, no
problem, right? Proceed as usual and
document in a PCR.

My patient wishes to refuse assessment,
treatment, transport, or all of the above….
The Process: Establishing Standards
for Competency and Capacity

Competency: Only a judge or physician can
determine whether a person is incompetent.

Capacity: EMTs are required to determine
whether a patient has the capacity to refuse
care.

To start, a patient must be
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18 years old
Alert to person, time, place, events (AAOx4)
Have a GCS of 15
The Process: Establishing
Capacity – a better way
It’s fairly easy to justify taking a sick person to the
hospital. Justifying why you left them at home takes a lot more
effort.
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Ultimately, the EMT must determine the patient’s
ability to comprehend the risks of refusing care
and/or treatment.
AAOx4 is a conclusion. Don’t rely on this alone.
How did you get there?

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Document the questions and the answers used to
determine mental capacity/competence.
You can use many methods to do so.
The Process: Establishing
Standards for Documentation
Best way to complete a refusal is to
complete a PCR as if the patient were
transported.
 Note anything that may affect capacity
(alcohol, drugs, head injury, blood loss),
MOI
 Review DAC Release of Liability Items 110

The Process: Establishing
Standards for Documentation
Complete the DAC Release Form
 Ensure items 1-10 are completed
 Obtain appropriate signature
 Obtain witness signature (who witnessed
items 1-10)
 Document items 1-10 in a PCR

The Process: Establishing
Standards for Supervision
Review items 11 and 12
 Whenever possible, EMTs should ask
medical control to supervise a patient’s
refusal of transport.

When do you complete the Against
Medical Advice section?
Arrive on scene
 Make contact with the person to whom you
responded
 The person DOES meet the criteria for a
patient
 The patient refuses transport by EMS
 Document all items in a PCR including that
the pt had the capacity at the time of
refusal.

When do you complete the
Juvenile/Incompetent/In
Custody section?
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Arrive on scene
Make contact with the person to whom you
responded
The person meets the criteria for a patient
The person is under the age of 18 OR
The person is considered legally or medical
incompetent OR
The person is in the custody of a law enforcement
agency
Document all items in a PCR
Review: Emancipated Minors in
NM

To be emancipated a minor must be at
least 16 and
1) has
been married, even if he no longer is;
2) is in the active duty military; or
3) has been emancipated by the court.
For example, a 14 year old who is married is
not emancipated. (32A-21-3).
Juvenile/Incompetent/In
Custody (cont.)
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It is not the EMS provider’s responsibility to medically “clear”
persons before they are transported to jail.
If contact is made and the patient is not treated or transported, a
signed release of liability must be obtained from the patient.
If the patient refuses or cannot sign because they are handcuffed,
document the verbal refusal and have the police officer witness it.
If the officer is refusing EMS transport for the patient, then that
officer must sign the refusal as the patient’s guardian.
As with any refusal, read the appropriate section of the liability
release to the patient/officer, document that and their apparent
understanding in the PCR narrative.
In the event we cannot obtain a signature for whatever reason,
document the “exception” in detail.
When do you complete the
Non-Patient section?
If the individual is not a patient, then there was no
relationship to begin with.
 Arrive on scene
 Make contact with the person to whom you
responded
 The person does NOT meet the criteria for a
patient.
 Per protocol - see next slide!
 Complete documentation per your agency’s
policy
Who is NOT a patient?
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Non-Patient. Use this section when a person has NO
MEDICAL COMPLAINT, INJURY OR ILLNESS. A
person who meets ALL of the following criteria is NOT
considered a patient if he or she:
Did not request an ambulance. Calls to 9-1-1 are not
always intended by the caller to be an ambulance
request, although an ambulance may be dispatched
(i.e. minor MVAs);
Presents with NO current physical or psychological
complaints/symptoms;
Has NO signs or symptoms of an active significant
medical illness or injury;
Is a legal adult; and
Is not under the influence of drugs including alcohol.
Who is NOT a patient?

It is up to the EMT to use their:
common sense
 and good judgment to determine who is a
patient and who is not a patient.
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 Complete
documentation per
your agency’s policy.
AMR Non-patient
documentation
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A PCR must be completed to account for
the run.
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In the narrative section give a brief
description of the events and why it
qualifies as a non-patient.
LCFD Non-patient
documentation in Red Alert
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A PCR must be completed to account for the run.
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Enter required info on a PCR (see video
In the PCR: In addition to the demographic information,
fill out the required fields:
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Turned over to: Enter “Non-Patient”
Disposition: Enter “4830” (No treatment Required)
Condition Code: Enter “-25” (Not Reporting)
Location, Symptoms, Provider Impression: Enter “-25”
C/C: Enter “Non-Patient/No complaint or injury” Use quotes.
Level of Care for Needed and Provide: “Non-Patient”
Reported Complaint, Location Type, Primary Cause of Injury,
Intend of Injury: “-25”
LCFD Non-patient documentation in
NFIRS
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NFIRS – Section C Incident Type
Use 322 for an MVA with injuries if there is at
least one patient.
 Use 324 for an MVA with no injuries and all
persons at the scene were non-patients.
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PATIENT CONTACT DEFINED
Discussion
Patient contact and
cancellations
The first due FIRE unit arrives on scene
 Makes contact with the person to whom you responded
 The person meets the criteria for a patient (or non-patient)
 Pt does NOT need ALS assessment and the patient refuses/may
refuse transport by EMS
 Fire unit makes decision to cancel or not to cancel the transport
agency
 If no pt contact made by transport agency – FIRE gets refusal
 If contact is made by transport agency or pt care is TOT transport
agency for whatever reason, transport agency gets refusal
documentation
 First due does not need to get duplicate refusal documentation
 First due unit documents in PCR that pt turned over for transport,
refusal or unknown disposition
Patient contact and
cancellations
First due TRANSPORT UNIT arrives on scene
 Makes contact with the person to whom you responded
 The person meets the criteria for a patient or (non-patient)
 Pt is assessed and the patient refuses/may refuse transport by EMS
 Transport unit makes decision to cancel or not to cancel the fire unit
 No pt contact made by fire unit – TRANSPORT AGENCY gets refusal
 Pt care should never be TOT from an ALS transport unit to a fire unit for any
reason
 Fire unit does not need to get duplicate refusal documentation
 Fire unit documents in PCR that pt turned over for transport, refusal or
unknown disposition
FIRST DUE UNIT CANNOT GET CANCELLED BY SECOND DUE UNIT
WHY?
AMR documentation
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Continue to use the “cancellation form”
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Complete Quicnet “bubble” form
LCFD NFIRS Cancellation
Codes
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You don’t make it on-scene.
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You arrive on-Scene and NO patient contact is made.
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NFIRS 622/No incident found on arrival at incident address; No
PCR
Medical Assists
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NFIRS 611/Dispatched and cancelled enroute and NO patient
contact is made; No PCR
311 with PCR (pt relationship does exist including vitals
taken, assisting with pt packaging and loading)
Lift Assists
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554 (5-Service call, 55 Public Service Assistance, 554 Assist
Invalid) OR
321 EMS call excl. accident with injury with PCR if you have a
patient
Other County Non-patient
documentation
 A Patient Care Report must be
completed.
 The ROL form must be filled out.
 The data must be entered into
NMEMSTARS as either a cancelled run or
no patient found.
Other county agencies
documentation
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Continue to fill out the Run form
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NMEMSTARS entry made for cancellation
For unusual circumstances…
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Call medical control
Call your supervisor
Cover your bases:
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Complete the Release of Liability form
Complete a PCR
Call your supervisor and/or Medical Director for
additional clarification
“Nobody will mess you up for doing too much
documentation.” – Rob Campion
Who’s Responsible?
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Everyone is responsible.
The highest level of provider on scene is
ultimately responsible for patient care.
Look up state statue
Multiple Patients
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How are MCIs categorized?
Figure out how many people are involved, regardless of
the categorization.
When it’s all said and done, the transporting agency and
the fire department should document
 The total number of patients involved
 How many were treated by the transport agency
 How many were treated by the fire department
 How many identified themselves as Non-patients
AMR Record Keeping
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The DAC Release of Liability Form will replace
the current “refusal” form in circulation.
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A PCR still must be completed in its entirety.
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A Quicnet “bubble” form must be completed
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Both forms will be inserted inside the PCR and
then placed in the shift envelope.
LCFD Record Keeping
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What forms get filled out and what goes
where?
Pt Assessment Forms, i.e., cheat sheets, will
be in duplicate – one for us and one for the
transporting agency and will be filed as below.
 Completed DAC Release of Liability forms –
they will be single – will be filed in a
designated file folder at the stations to be
collected at each station each week to be filed
by the department.
 If any person wishes a copy of a release,
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County Agencies
Record Keeping
 The new ROL form will replace any refusal
forms in use
 The ROL form will be kept with a copy of
the NMEMSTARS report, or run form
currently being utilized by the agency
 Each call should generate a run form
(paper or NMEMSTARS)
 Each call will be entered into
NMEMSTARS
In a nutshell…
Your interactions will always depend upon
your assessment of the scene and/or the
patient.
 Failure to document those assessments
can open the door to claims of
abandonment or other forms of
negligence.
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QUESTIONS?