Multiple Patient Refusal/release Form - Silver Cross Ems System printable pdf download

Multiple Patient Refusal/release Form - Silver Cross Ems System

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SILVER CROSS EMERGENCY MEDICAL SERVICES SYSTEM

TITLE:

MULTIPLE PATIENT REFUSAL/RELEASE FORM

POLICY:

Silver Cross EMS System provider agencies may utilize the system’s Multiple Patient Refusal/ Release

Form to expedite the processing and documentation in situations involving multiple patients that refuse

prehospital care and transport to a medical facility.

In order for provider agencies to utilize the system’s Multiple Patient Refusal/Release Form, the

following conditions must apply:

Multiple Patient Refusal/Release Form Criteria

An event that produces three (3) or more patients refusing prehospital treatment and/or

transport to a medical facility.

Multiple patients are adults (18 years old and older).

In the best judgement of the EMS providers, the individuals involved in the multiple

patient incident do not need treatment or transport, are awake, oriented and competent,

who are voluntarily refusing assessment.

NOTE:

Medical control should be established with the resource hospital early in the

incident and prior to releasing patients from the scene.

II.

Incident Documentation and Circulation of Report Forms

At least one (1) ambulance response report form on electronic or written format must be

completed for each incident that involves the use of the System’s “Multiple Patient

Release” form.

System agencies must forward copies of completed “Multi-Patient Release” forms to the

System. All essential data must be entered into the electronic data collection program.

EFFECTIVE DATE:

05-01-96

REVISED DATE:

11-15-11

REVIEWED DATE:

Manual Page: 300-65

Multiple Patient Refusal/release Form - Silver Cross Ems System