A NSW paramedic says:
There is a debate amongst paramedics regarding documentation when a patient has refused assessment/treatment/transport.
The common practice at the moment is for paramedics to make their recommendations and if the patient refuses (and has competency and capacity), to explain the risks of non-transport, and have them sign the eMR (this section of the eMR has a disclaimer essentially saying they’ve been assessed, and are refusing the recommendations of paramedics, and that the sign understanding the risks of not following the recommendations.
Paramedics will then complete the case sheet in the car, either at scene, moved away from the scene or on route to station.
One paramedic is saying that we are risking litigation and coroners if we do not complete our case sheet on scene and have the patient read our case sheet prior to them signing the eMR (as they have not read the final article).
The other side being argued (by me) is that a patient signing is only signing the disclaimer not the case sheet, and they do no need to agree with the case sheet, nor are they entitled to read our case sheet. If they choose to, they can apply under freedom of information for their case sheet, but their signing is not related to the rest of the case sheet – only the disclaimer.
It’s our job to ensure they have competency and capacity, are well informed of the risks and for us to document clearly.
A patient in hospital has no right to read their notes without appropriate approval through freedom of information- it should be no different for patients in the pre-hospital setting.
What’s your take on this?
I infer eMR stands for Electronic Medical Record (see https://www.ehealth.nsw.gov.au/solutions/clinical-care/electronic-medical-records/emr).
The publicly available NSW Ambulance Protocol P2 Patient Refuses Paramedic Recommendation says paramedics:
- Complete a clinical record and document in addition to the standard documentation requirements:
- The recommendations made by paramedics and the rationale for making them
- The reason(s) for the Pt/PR [patient/person responsible] refusing consent and any attempts by paramedics to reconcile the reasons stated, including any external parties involved (e.g. GP, Family/Friends etc)
- All advice provided by paramedics to the Pt/PR
- Request the Pt/PR to sign the clinical record disclaimer for refusing paramedic advice – if the Pt/PR refuses to sign the disclaimer, document their reason(s) for refusing to sign
- Provide Pt/PR with a Referral/Advice Letter and the relevant patient information sheet/s
This protocol does not suggest that the patient is required or is to be requested to sign off on the entire case sheet nor are they asked to read the case sheet. They are being asked to sign off on a statement that confirms the paramedic’s advice and their decision to refuse treatment/transport. Having said that, I can see both sides of the argument.
The starting point is that a medical record belongs to the author or where the author is an employee, it belongs to the employer (see Breen v Williams [1996] HCA 57 and Health Services for Men Pty Ltd & v D’Souza [2000] NSWCA 56). The eMR is therefore the ambulance service’s record, not the patient’s, nor is it a joint document.
In the eMR the practitioner records their observations and their conclusions. Like a doctor a paramedic may record things told to them in confidence by others or make observations that inform their decision making but which are not intended to be shared with the patient. That they are the paramedic’s, or the ambulance service’s records means there is no need for the patient to sign or read them.
But one can see why that might be desirable. The issue that I can foresee is that if the patient suffers an adverse outcome and the paramedic says ‘I explained those risks and the patient still refused treatment/transport’ the patient (or other witnesses) may dispute what was said or what advice was given. If, so the argument would go, the patient has signed the completed eMR then their signature could be taken as an endorsement of what was said and one could point to the observations recorded on the eMR along with their signature as an implied adoption, by the patient, that what was said on the eMR was correct.
But there is no guarantee that the patient’s signature on any document will be effective; the outcome would depend on all the circumstances. First a patient is unlikely to understand that they are being asked to endorse the contents of the eMR. If that was not their intention, then the signature is not an endorsement. Further to accept that their signature is in effect to adopt what was written implies that the patient has both the time and the capacity to read and understand what was written and what it all means. Case records will be written with acceptable abbreviations, boxes ticked etc. The patient cannot confirm what you recorded as their vital signs, nor can they confirm your opinions. Depending on the patient and the circumstances their signature may mean nothing or no more than ‘I signed the paper to make them go away’.
Remember too that the patient is under no obligation to sign the paperwork or cooperate with the paramedics. So, if the patient has made it clear that they do not want treatment and transport and they want the paramedics to leave then the paramedics cannot stay on the premises to complete the paperwork nor return to ask the patient to sign the paperwork so getting the patient to sign the disclaimer and then leaving to complete the paperwork might be the best option.
Conclusion
I agree with my correspondent that ‘a patient signing is only signing the disclaimer not the case sheet, and they do no need to agree with the case sheet, nor are they entitled to read our case sheet… their signing is not related to the rest of the case sheet – only the disclaimer’. What you are asking the patient to do is endorse that you have given them advice and they are rejecting that advice not to endorse the observations you have made and the opinions formed.
Provided the data recorded on the eMR is correct, it doesn’t matter in which order it was completed. Taking the time to complete the entire eMR before asking the patient to sign off on their refusal might be ideal as it does mean a paramedic could take the patient through each set of observations and explain why that leads to their opinion that the person would benefit from further treatment/transport. But it’s not essential and could be done even if the eMR has not been completed.
Remember too that the patient can refuse treatment for any reason or no reason at all and they are not obliged to assist you with your paperwork so trying to stay on scene to complete the eMR may escalate a situation or at least be inappropriate. If the patient/person responsible wants you to leave, or to leave them alone, then getting a signature confirming the patient’s decision to refuse treatment may be the best you can get and then you have to go and complete the details after the patient, or you, have left the scene.
This blog is made possible with generous financial support from (in alphabetical order) the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), the Australian Paramedics Association (Qld), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.
This blog is a general discussion of legal principles only. It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.
Australian Emergency Law 
If this discussion opens up the question of “If a patient signing the eMR Disclaimer proves nothing other than that they signed the Disclaimer – not that they understood the paramedic’s advice” then that includes a wider range of situations, such as those where paramedics attend but do not need to transport the patient, instead either recommending self-treatment or visiting a GP.
It almost produces a situation where recording audio of the interaction (not necessarily the whole interaction, but just the end) would serve that purpose. Like body camera footage from a police officer advising a detainee of their rights and having them confirm verbally that they understand those rights.
Being able to rely on an audio recording of…
Paramedic: “For the purposes of our records keeping, my name is [NAME], I am at [JOB NUMBER] and I am speaking with the patient [PATIENT NAME]. Do you give permission for us to make a record of this conversation?”
Patient: “Yes”
Paramedic: “So, [PATIENT], based on our discussion today, and the checks I have done, I believe that [PRELIMINARY DIAGNOSIS]. Do you understand?”
Patient: [YES/NO/QUESTIONS]
Paramedic: “I would like to take you to hospital so they can do some further testing to confirm and decide on treatment. Is that OK?”
Patient: “No. I don’t want to go to hospital.”
Paramedic: “It is your right to refuse treatment. I still recommend we take you to hospital. Are you refusing to go to hospital with us?”
Patient: [YES/NO]
Paramedic: “OK. Can you please sign here confirming that choice.”
Patient: {signs eMR Disclaimer}
Something like that would be the “belt & braces” approach. If the paramedics, or their employer, are worried about a patient trying to come after them in court.
Obviously, the recording would need to be protected and stored with the same protections as the notes. And if the content of the recording didn’t align with the paramedics notes, that would be an issue. But it takes it from a signature to a statement saying “The paramedic told me something, but I’m refusing treatment.” to a much more detailed and nuanced piece of evidence.