Patient Refusals in Emergency Medical Services

What must the EMT ensure is completed and signed by the patient when they refuse care?

In the ImageTrend NEMSIS 3.5 system, what patient disposition should be selected by the ePCR report writer when a patient refuses care?

Where should the signed refusal form be uploaded after it is completed?

What should be done if the report writer is unable to scan and upload the refusal form into the ePCR?

Who is responsible for scanning and uploading the signed refusal form if the report writer cannot?

What additional information must the ePCR report writer document about the patient’s refusal?

STJFD responds to various medical incidents, from low acuity to cardiac arrest.
When a patient refuses care or transport, STJFD personnel must follow specific procedures.

The EMT must complete and obtain the patient's signature on the STJFD patient refusal form.
In the ImageTrend NEMSIS 3.5 system, the person completing the ePCR must select "refusal" as the patient disposition.
The ePCR report writer must document the patient's orientation and education of refusal in the designated tab.
The signed refusal form must be uploaded into the ePCR in .pdf format.

If the report writer cannot scan and upload the refusal form, the original signed form must be placed in a sealed envelope addressed to the Chief Medical Officer.
The envelope must be delivered to headquarters within 48 hours of the incident.
The Chief Medical Officer will scan and upload the signed refusal form and attach it to the ePCR.