EMS Refusal of Care Documentation Audit

Audit template for reviewing EMS refusal-of-care documentation, including capacity assessment, risks explained, alternatives offered, and signature capture.

Audit Details

• Encounter date and time documented
• Unit, crew, and patient encounter identified
• Refusal type documented
• Documentation reviewed against agency refusal policy or SOP

Capacity Assessment

• Decision-making capacity assessed and documented
• Patient alertness and orientation documented
• Mental status, intoxication, or altered condition addressed
• Patient able to communicate understanding, choice, and reasoning

Risk Explanation and Alternatives

• Risks of refusal explained in specific terms
• Potential for worsening condition, disability, or death documented
• Alternatives offered, including transport, further evaluation, or continued treatment
• Patient questions answered and understanding confirmed

Refusal Documentation and Signatures

• Patient refusal signature captured
• Witness or crew signature captured when required
• If patient refused to sign, refusal to sign documented
• Refusal form is complete with no missing required fields

Post-Refusal Instructions and Final Disposition

• Return precautions or follow-up instructions documented
• Patient advised to call 911 / seek immediate care if symptoms worsen
• Final disposition documented