A Victorian paramedic wants to know
… how much legal standing having a patient sign your Patient Care Record acknowledging they do not wish treatment or transport carries?
I’m talking about cases here where you assess a mentally competent patient, deem they probably should go to hospital to be treated for whatever, but they decide they don’t want or need to go. Our case sheets here carry a disclaimer broadly stating that the paramedic has assessed the patient and advised them they should go to hospital.
If the patient wishes to refuse transport, that is fine, but we are then supposed to get them to sign, in fact policy requires us to get them to sign. Notwithstanding it is a policy requirement, I am wanting to know the legal strength, and what if the patient refuses to sign?
The other point is, we are getting the patient to sign a PCR that we have not fully completed, in most cases we would have just entered their personal details and the rest would be added later when we clear the scene. Would this have a bearing if, for whatever reason, the case later went to court?
Over the years, I have heard varying opinion – from you NEED to get this signed to protect yourself from any adverse events, – right through to “it makes no difference legally whether the patient signs or not”
The patient’s signature on the Patient Care Record is evidence confirming the details are true. But the details of what? Not the details on the PCR but whatever it is they are being asked to sign. Let me explain. In NSW a patient is asked to sign a Non-Transport Declaration (I use NSW even though my correspondent is from Victoria, as I couldn’t find the Victorian equivalent online, but a NSW form was online (Patient Health Care Record SOP (Version 4.0 July 2009), <http://www.ambulance.nsw.gov.au/media/docs/phcr_version_4-ab6dab58-37b5-453c-8fda-720f86212df0-0.pdf> p 65). I’ll assume that the Victorian (and all states’ equivalent) is in similar terms.
So in this case the patient is acknowledging that they understand they have been assessed, that a full and complete medical examination is not possible, and that if there is any change they should seek further advice. They are not certifying that everything on the PCR is correct – they couldn’t in any event certify what the paramedic found on examination, what treatment if any was given, what observations were made or conclusions drawn. So the first point is that it doesn’t really matter that they are being asked to sign even though the PCR is not fully completed; but we’ll come back to that.
If the document is evidence then that is the extent of its legal standing. It doesn’t prove that the patient has indeed been assessed by paramedics, or that they do in fact understand that if there is any change they should seek further advice but it raises evidence that that is the case.
Assume that shortly after leaving the scene the patient collapses and does end up in hospital with a serious and critical illness or injury and the question becomes ‘why didn’t the original crew transport?’ If the patient says ‘they told me I didn’t need to go’ or ‘they refused to take me even though I begged them too’; then the patient’s signature on that form will be evidence against those claims and he or she will have to explain how their signature got there. That is not impossible – “I didn’t know what I was signing”, “They told me I had to”, “I couldn’t read it” etc. All of that evidence goes into the mix for a judge or jury to decide what they believe actually happened.
These things (documents and forms generally, not just this one) really come to grief when they are used because people believe they have to be, or that they are a guarantee, even when it’s not for a proper purpose. A clear example in this context would be using a ‘Refused treatment’ form when really what you mean is ‘Paramedic advises patient treatment not required’. I see now that NSW Ambulance has a ‘Patient Transport Decision’ form (see below):
Once upon a time though recommending non-transport was frowned upon so people would claim the patient had refused transport when clearly that was not the case (see Transport everyone or act as a professional? A question for paramedics (May 6, 2013)). In that case getting a person to complete a card saying ‘I refuse treatment’ when really what happened is ‘I have been advised I don’t need treatment’ just brings everyone into disrepute and is likely to make a court view any evidence with suspicion.
It follows that the absence of a signature doesn’t prove anything either. You can’t make a patient sign the document. If they don’t the paramedic can still give evidence as to the conversation that occurred and the circumstances in which advice was given, rejected and the patient refused to sign the declaration. Critical here would be the paramedics ‘contemporaneous notes’ that is notes written at or soon after the time of the event where you record what happened and what was said (and try to record conversations in the first person ie I said …; he said ….’).
Conclusion
The questions I was asked were:
… how much legal standing having a patient sign your Patient Care Record acknowledging they do not wish treatment or transport carries?
Answer: its evidence that the things stated on the card are true – using the NSW example the signature is evidence that the patient understood that they had been assessed, that a full and complete medical examination was not possible, and that if there was any change in their condition they had been advised to seek further advice. Having said it is ‘evidence’ means it does not prove, conclusively that those things are true, but the presence of the signature ‘could rationally affect (directly or indirectly) the assessment of the probability’ that those things did in fact happen (Evidence Act 1995 (NSW) s 55).
… and what if the patient refuses to sign?
Again that is evidence. If in court the patient says ‘I didn’t sign because it wasn’t true’ then the absence of signature might suggest that is the case. If the paramedic’s evidence, supported by notes taken at the time that says something like:
‘Patient refused treatment and left the scene. I said ‘Excuse me sir, I really think you should come with us to hospital, I’m really concerned about your injury’. He said ‘F#@- off’ [but in your notes you would actually write the words used, but this is a public blog]. I said ‘would you mind signing this form just to confirm that I’ve explained the situation to you. He said ‘F#@- off’ and left the scene in a car driven by a person I didn’t know.
Then the absence of signature could confirm that version too.
… we are getting the patient to sign a PCR that we have not fully completed, in most cases we would have just entered their personal details and the rest would be added later when we clear the scene. Would this have a bearing if, for whatever reason, the case later went to court?
As I said that doesn’t really matter as the person isn’t endorsing the entire PCR. That may be an issue if the suggestion is that you completed the PCR after something went wrong. So the patient refuses treatment, you move onto the next job, then the next and then you see your patient in the resus bed at hospital and realise things have gone from bad to worse so you then get out the PCR and start filling it out with the ‘Refused Treatment’ declaration right there in front of you. There may be some room for suggestion that in then filling out the PCR you put entries in, or omitted them, in order to make the decisions appear more ‘reasonable’. That’s got nothing to do with the Non-transport declaration really, just the need to complete records ASAP and not when you begin to think they might actually be called for.
Over the years, I have heard varying opinion – from you NEED to get this signed to protect yourself from any adverse events, – right through to “it makes no difference legally whether the patient signs or not”
It really does make ‘no difference legally whether the patient signs it or not’. Should the issue arise the issue will be – did the paramedic explain the situation to the patient and did the patient competently refuse treatment? The signed form is part of the evidence to go into the mix for the court to consider.
Australian Emergency Law 