Policy:
All patient encounters responded to by EMS will result in the
accurate and timely completion of the appropriate Patient Care Report (PCR)
and/or patient discharge instruction (disposition) form.
Purpose:
To provide for the documentation of:
·
The evaluation and care of the patient.
·
The patient’s refusal of the evaluation, treatment, and/or
transportation.
·
The patient’s discharge (disposition) instructions.
·
To protect the local EMS system and its personnel from undue
risk and liability.
Procedure:
1.
All patient encounters, which result in some component of an
evaluation, must have a PCR completed.
2.
All patients who refuse any component of the evaluation or
treatment, based on the complaint, must have an ICEMS Refusal of Treatment and
Transport form completed.
3.
All patients who are not transported by EMS must have an
ICEMS Refusal of Treatment and Transport form completed.
4.
Minors (anyone less
than 18 years of age) cannot refuse treatment or transportation.
Only a parent or legal guardian can refuse treatment or transportation for a
minor. Refusal may be obtained in one of two ways: 1) in person, or 2) by direct
telephone contact with a law enforcement officer as a witness. Absent these two
methods of verification, the minor will be transported for further evaluation to
the closest, appropriate medical facility. Do not delay treatment or
transportation in order to obtain permission for refusal of care.
5.
Refusal forms must have all pertinent information such as
LOC, VS, and signatures completed prior to departing the scene.