One source states that every negligence case in the last 30 years has been decided on its documentation.
 
I will admit that in the past I have rushed through documenting a refusal probably, leaving out critical information.  I mean after all we didn’t even transport.  I no longer do this.  In fact I take extra care when documenting refusals.
 
Court Case Ruling Summary:  The paramedics had failed to fill out several of the evaluation categories on the run form and had been in too much of a hurry to complete the report, indicating an incomplete evaluation in violation of a state statute requiring a “full evaluation” prior to a decision not to transport. In particular, a box regarding “fainting” was not marked despite the initial call for a patient who had passed out.  The trial court also found that the son’s signature on the refusal form was invalid, because he was not adequately informed of his mother’s condition due to the incomplete assessment.

The courts quite literally follow the old saying “if you didn’t document it you didn’t do it”.

A properly documented PCR communicates competency and credibility, and that documentation can prevent allegations of negligence.

Be sure to include the following in your PCR.

• Physical examination findings.
• Vital signs
• Factors that may affect a patient’s ability to reason (e.g., the presence of drugs or alcohol)
• Treatment offered
• Fully document that the patient had the capacity to refuse care at the time of the encounter.  A patient’s condition may change from one hour to the next.  If it is not documented in the PCR, and if a patient thereafter experiences a diminished capacity, a judge or jury might not believe the patient had capacity to refuse during the time of the encounter.
• Document exactly what you told the patient were the risks of refusing.
• Document what the police tell you about the patient, especially if it is different from what you document you observed about the patient.   Any differences need to be addressed because the PCR and police report will be compared.
• Document the reason the patient is refusing care if given.
• Document that you told the patient you were willing to transport the patient now or later if the patient changed his  mind.
• Document the patients plan of action.
• Will be going POV
• Will call 911 is change in status
• Will make appointment with primary care doctor
• Slams door in your face.  Whatever it is, document it.
• Document who you left the patient with.
• Ensure the patient knows that this release is for this incident only

 
Patient refusals are tedious, but they are vital documents to protecting the EMT and the agency from lawsuits. Careful attention to detail will provide ample protection. Remember that these documents are not for the protection of the patient, but are designed to protect the providers.

It can not be stressed enough that If it wasn’t written down, it wasn’t done.

Tips on the Refusal Form

• Ensure the patient knows that this release is for this incident only
• Explain what a release from liability is.  Verify the patient understands what he/she is signing
• Write the potential risks on the form
• Have the patient sign the form in front of at least one witness if present
• Have the witnesses sign if present
• When possible leave the patient in the care of family, friends or guardian.