A-6.2 Ems Patient Refusal Checklist - Southern Illinois Regional Ems System
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1Southern Illinois Regional EMS System
A-6.2 EMS PATIENT REFUSAL CHECKLIST
Name: __________________________________________ Age: _______ Date: ______________
Nature of call: ___________________________________________ Run Number: ______________
Assessment of Patient: (complete each item, circle appropriate response)
Oriented to: Person? Yes No Place? Yes No Time? Yes No Situation? Yes No
Possible head injury?
Yes
No
Possible alcohol/drugs ingestion by exam or history?
Yes
No
Age 18 or over?
Yes
No
Abnormal blood glucose? Yes No
Abnormal SA02? Yes No
Vital signs
General impression
Medical Control:
____ Contacted by: ____Radio
____ Phone
at _______________ hours
____ Unable to contact. (explain in comments)
Orders:
o ____ Indicated treatment and/or transport may be refused by patient.
o ____ Use reasonable force and/or restrains to provide indicated treatment.
o ____ Other:___________________________________________________________
Patient advised: (complete each item, circle appropriate response)
Yes
No
Medical treatment/evaluation needed.
Yes
No
Ambulance transport needed.
Yes
No
Further harm could result without medical treatment/evaluation.
Yes
No
Transport by other means could be hazardous due to patient’s present illness/injury.
Yes
No
Patient informed, if appropriate, that there is a potential threat to life/limb.
Yes
No
Patient provided with Patient Refusal Information Sheet.
o Type of refusal:
____
Refused all EMS services.
____
Refused transport, accepted field treatment.
____
Refused field treatment, accepted transport.
____
Released in care or custody of self.
____
Released in custody of law enforcement agency:
Agency: _____________________________
Officer: ______________________________
o ____ Released in care or custody of relative or friend:
Name: _______________________________
Relationship: __________________________
Comments:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Crew member signature: ____________________________
Time: _________ Date: __________
Revised 03/2012
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