Enhance Patient Refusal Documentation

Patient refusals are a very sensitive issue and our claims experience shows these can become very complicated and difficult to defend when litigated.  Problems occur when a person who has refused treatment and/or transport, suffers harmful consequences after EMS leaves.  Some of the significant legal questions that arise are:

1. Can it be determined what information the patient was given to make the decision to refuse treatment and/or transport?
2. Did the patient have the capacity to make an informed decision?
3. Did they fully understand the risks that they were taking by refusing treatment or transport?
4. What options were given to the patient if they changed their mind regarding treatment or transport?
5. Did the signed form include legal language which could not be easily understood?

Many of these problems are as a result of the use of an improperly developed or processed patient form. Our experience finds that many existing Patient Refusal Forms are improperly written and/or formatted.  These weaknesses may cause confusion and potentially weaken the defense of the form.  Additionally, financial responsibility clauses or insurance releases should never be included on the patient refusal form. 

Your organization currently utilizes a patient refusal form.  However in review of this form, we feel there are a number of areas on the form which contain either undesirable language or information which could be improved.  Please review the referenced sample form for comparison.  The information on the referenced form may be used by your service in whole or in part. Any modifications you make to your form should be reviewed by your attorney prior to use.  We are also referencing our Medical Miranda card on the section which follows. The use of this tool will help ensure proper information is communicated to persons refusing treatment or transportation to a medical facility.

Available Resources

• EMS Patient Refusal Checklist - Spanish
• EMS Patient Refusal Information Sheet
• EMS Patient Refusal Checklist