Processing the Patient Refusal

Documentation is key when it comes to patient refusal calls.

Kevin Collopy, Sean Kivlehan and Scott Snyder are featured speakers at EMS World Expo 2013, September 8–12 in Las Vegas, NV, and will present on several topics including Pediatric Spinal Immobilization, Hot Topics in EMS and Case Studies in Medical Emergencies.

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to to take the test and immediately receive your CE credit. Questions? E-mail


  • Highlight the risks around completing a patient refusal
  • Explain the different assessments performed while processing a patient refusal
  • Discuss patient refusal documentation

You and your partner are dispatched to the home of a 50-year-old woman who “just doesn’t feel well” and wants transport to the emergency department. On the way to the scene your partner says, “It’s flu season and I’ve been to 10 of these in the last week. I don’t know why these people call an ambulance, when all they need to do is stay at home and rest.”

Upon arrival, you find a clean house but the mail is piled on the floor just inside the door, the light on the patient’s answering machine is blinking with unheard messages, and there is no sign the patient has been out of the house in days. Her friend called you to take her to the hospital, and insists that “she has to go.” He tells you she has been home from work for three days, has been vomiting and just won’t get out of bed. The friend tells you this woman is very active and is always up and doing something. He also says the patient has a history of cardiac problems and high blood pressure.

Your partner asks the patient what’s going on. She insists she’s fine: “I feel achy, haven’t had much energy lately, my arms feel tired, but I’ve felt like this for several days.” She says her friend is “overprotective” and she doesn’t want to go to any hospital. Your partner states that although it’s flu season, she should have an evaluation at the emergency room. She still insists she’s “not going anywhere. I’ll be fine.”

The patient’s vitals are taken and she has an irregular heart rate of 68, blood pressure of 180/90 and respiratory rate of 18 with rhonchi in the bases. Your assessment leads you to the conclusion that this patient needs to be evaluated at the emergency department, but your partner tells her, “If you don’t want to go, I cannot make you come with us,” and has her sign the paperwork for refusing treatment and transport to the hospital. Her friend insists, “You need to take her to the hospital! Something is going on with her and she’s not her normal self.”

Something just doesn’t sit right with you. You want to ask more questions but also don’t want to undermine the authority of your senior partner. You are about to ask the patient some more questions and tell her to call 9-1-1 again if she doesn’t feel any better, when your partner says, “Let’s go, we’re all done here.” On the way back to the rig your partner says, “It’s your call, you’re going to write the refusal, right?” What are you going to do? How are you going to document this call? What important information do you document? Would you refuse to write the prehospital paperwork and make your partner do it because he conducted the assessment?


Patient refusal calls are some of the most dangerous EMS providers respond to, not because of the situations crews are presented with, but because of the liability of not taking the patient to the hospital. This liability can result from many different factors, including not doing a complete assessment, missing signs or symptoms of a major illness, or not properly documenting everything that was said, done and witnessed. Ultimately, a family member may decide to sue the EMS crews and agency for damages because the patient was not taken to the hospital and something negative happened afterward.

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