Question

You are on a call of a minor vehicle accident. your patient is a 22-year-old male who was the driver of a moderate t-bone collision. the patient was not wearing a seat belt and there was spidering of the windshield. the patient complains of neck pain and has a scalp laceration. after performing the primary assessment, you take vital signs and bandage the patient's scalp. when you tell him you need to backboard him, he refuses care and ambulance transport. because the person is alert and oriented to time, place, and person, you have the patient sign the separate patient refusal form provided by your service. how should you document this incident in your ems report?

Answer 1

one should document everything as to include all patient​ care, all of your exertions to convince the patient to be accompanied in an ambulance, and who are the witnesses in the patient's refusal. A signed waiver could also be of help so that it is a proof that the patient refused the treatment.