A Patient Refusal must be documented whenever:
- The Patient has an injury or illness and refuses assessment, treatment, and/or transport
- The Patient refuses a procedure such as an IV, oxygen, or EKG that you have deemed necessary even if the Patient agrees to other treatments and/or transport
- You respond to a car accident and the driver tells you they are not injured and they do not want to go to the hospital.
This would not require a refusal.
- You respond to a car accident and driver complains of bruises on their arms from the airbags.
This person has been injured and a Patient Refusal should be documented.