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1、 Clinical Protocols yet declines transport. Check this box if the patient receives EMS treatment but then refuses transport. (i.e. hypoglycemic patient who receives glucose and wakes up, or patient with history of SVT who adamantly refuses transport post conversion of SVT with adenosine). Medic shou
2、ld document medication and dose administered on the line provided. Patient deemed competent, refuses; indicate which treatment the patient refused, buts agrees to transportation. (check this box only when a patient (or legal guardian) has agreed to ambulance transport but is refusing EMS recommended
3、 care. Patient refuses Air-Medical Transport, but agrees to ground ambulance transportation. Check this box only when the patient agrees to ground transport but adamantly refuses helicopter transport. Section C: PATIENT/GUARDIAN/POWER OF ATTORNEY HAS BEEN ADVISED Of pre-hospital treatment and/or tra
4、nsportation options. Check this box and list all transport and/or pre-hospital treatment options.(i.e. patient transported by family, continuous monitoring and transport recommended for patient declining transport after adenosine conversion etc) That transport by means, other than by ambulance, coul
5、d be hazardous and is not recommended based upon current condition / complaint, specific injury or medical illness. Check if patient declines EMS offer of transport and the potential for deterioration could occur. (i.e. chest pain that decides to go by private vehicle) That significant risk(s) could
6、 be involved with refusal of EMS treatment and/or transportation, related from, but not limited to; exacerbation of present complaint / condition / injuries, or the possibility of significant disability and/or death occurring from refusal of emergency medical care or transportation. Patient has been
7、 informed of their right to refuse pre-hospital treatment and/or offer of transport to an appropriate medical facility (after being advised of potential complications) and appreciates consequences of his/her decision. That it is the preference of CCEMS to provide transport to the closest appropriate
8、 medical facility for further evaluation and treatment. Section D: PATIENT SIGNATURE (this section to be completed by patient or patient representative) Have patient or patient representative 9not the medic) read and check all appropriate boxes in this section in which they are refusing. Recommended
9、 treatment Ambulance / air transport Myself Minor less than 18 Other: _ check this box if they are declining care or transport for another person in their charge. List name of person on line they are assuming responsibility for. Patient / Patient Representative Signature (must be of legal age) Date
10、(actual date signed) Print Name Patient deemed competent, but declines or refuses to sign form: this box is checked whenever a patient is deemed competent through methods listed in section A, and adamantly refuses to sign the form. EMS Medic Signature: signature of medic completing the form. This si
11、gnature is only to verify that patient declined offers of care or transport and further declined to sign refusal form. (continued on next page) Clinical Protocols and Medical Directives25Calhoun County Emergency Medical Services (continued) Date actual date signed Print Name name of medic Witness Si
12、gnature (must be of legal age) Date actual date signed Print name name of witness PATIENT REFUSAL OF TREATMENT AND / OR AMBULANCE / AIR TRANSPORT Sections A. B and C completed by EMS Medic, Section D by patient or patient representative A.MEDICAL DECISION-MAKING CAPACITY: (Section must be completed
13、by provider) 1.New onset of altered mental status?YE S NO 2.Known or suspected acute head trauma?YE S NO 3.Active suicidal ideations or evidence of recent self inflicted harm present? YE S NO 4. Does patient present as a significant life-threat to self or others (i.e., unable to care for minor (s) i
14、n their charge, continually attempts to enter an unsafe area, or exhibits unsafe behavior)? YE S NO 5. Is a communications barrier present and patient is unable to understand information in order to make an informed decision or communicate a choice? YE S NO 6. Is patient unable to comprehend the cur
15、rent situation and its consequences? YE S NO If YES is checked to any of questions 1-6. and patient is refusing EMS transport, they may not have adequate decision making capabilities. Contact an EMS Supervisor or Law Enforcement for resolution and patient disposition. B. ASSESSMENT / TREATMENT REFUSED: (Check any that apply) Patient deemed competent, declines all EMS care and further refuses all offers of ambulance transportation Patient deemed competent, accepts the following pre-hospital care; _ _ yet declines transport. Patient deemed competent, refuses; IV access Oxygen Spinal im
