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Run: EMS Refusal of Care Documentation Audit

Audit EMS refusal-of-care documentation for capacity, risk disclosure, alternatives offered, signatures, and final disposition so incomplete refusals are cau...

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Audit Details

Encounter date and time documented

Unit, crew, and patient encounter identified

Refusal type documented

Documentation reviewed against agency refusal policy or SOP

Yes No N/A

Capacity Assessment

Decision-making capacity assessed and documented critical (required)

Yes No N/A

Patient alertness and orientation documented

Mental status, intoxication, or altered condition addressed critical (required)

Yes No N/A

Patient able to communicate understanding, choice, and reasoning critical (required)

Yes No N/A

Risk Explanation and Alternatives

Risks of refusal explained in specific terms critical (required)

Yes No N/A

Potential for worsening condition, disability, or death documented critical (required)

Yes No N/A

Alternatives offered, including transport, further evaluation, or continued treatment

Patient questions answered and understanding confirmed

Yes No N/A

Refusal Documentation and Signatures

Patient refusal signature captured critical (required)

Witness or crew signature captured when required

If patient refused to sign, refusal to sign documented critical (required)

Yes No N/A

Refusal form is complete with no missing required fields critical (required)

Yes No N/A

Post-Refusal Instructions and Final Disposition

Return precautions or follow-up instructions documented

Yes No N/A

Patient advised to call 911 / seek immediate care if symptoms worsen

Yes No N/A

Final disposition documented

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