The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason and in my opinion has the capacity to make decisions. The patient presents with no injuries following _____. I have explained that she may have other injuries that have not yet presented themselves; they have verbalized an understanding of my concerns.
Rescue advised that transport by ambulance would allow for a timely physician assessment and hospital resources that might be beneficial and are beyond Rescue’s capabilities. Rescue informed the patient that treatment/transport via Rescue may prevent a condition from worsening and that transport by ambulance could allow medical providers to manage unforseen complications. A delay in treatment may result in irreversible damage, loss of limb, or even death. Rescue advised the patient that transport by a private vehicle may result in worsening patient condition with no medical staff available; however, private transport is still preferable than no physician assessment at all. The patient is not willing to be treated nor transported, has acknowledged the risks and benefits of transport, and is refusing treatment and transport via Rescue. Rescue answered all of the patient’s questions before completing the refusal form and returning to service.