A PCR must always be completed when patient contact is made and when the patient refuses treatment or transport. The paramedic must obtain an accurate history, complete a full physical exam, and document a full and complete set of vital signs.
Refer to Policy BCEHS OPS 010.1 Patient care Report SOP. Section 5.
The paramedic or EMR must obtain and document:
If at any point you are unable to meet these requirements, you must provide an explanation in the narrative section of the ePCR.
☎️ Mandatory CliniCall consultation for refusal of conveyance -for a complete list of circumstances when to contact CliniCall, please refer to CliniCall Support Services CPG. The list is long and should be referenced before the release of liability signature is obtained. Even if your patient does not meet criteria for mandatory call, but you feel conveyance is in your patient’s best interest, calling CliniCall Support Services.
Reference: A04: Duty of Care CPG, Section 5: Refusal of Care and A09: Non-Conveyance & Refusal of Care
Refusal of Transport and Release of Responsibility: It is important to respect the patient’s autonomy and their right to refuse care even if it goes against your values. But it is your fiduciary responsibility to ensure the patient is making an informed decision. This means they must be explicitly informed of the risk of refusal based on their complaint and/or condition. Even if your patient does not meet any of the criteria in the above list but you are not 100% confident you can explain the risk of refusal, contact CliniCall for assistance.
Read aloud the Release of Responsibility paragraph to the patient if English is the patient’s language of choice; or have the patient read the Release of Responsibility from the Siren Hardware if their language of choice is one of French, Traditional Chinese, Simplified Chinese, Punjabi, Arabic, Farsi, Italian, Japanese, Korean, Russian, Tagalog or Spanish. If the patient read the Release of Responsibility in a language other than English, enter details in the Comments
Confirm that the patient is competent (or has capacity to understand the risk) and understands what they are refusing. This is critical, pursuant to the PHSA Consent to Health Care Policy and the PHSA Consent to Health Care: Procedure for Minors and Mature Minors.
Minors and Mature Minors: If your patient is under the age of 18, refer to the PHSA policy Consent to Health Care: Procedure for Minors and Mature Minors to confirm they meet criteria to have capacity to understand the risk of refusal.
Patient and Witness Signature:
Patient: Have the patient sign the ePCR when you are satisfied, they understand the Release of Responsibility statement. Every reasonable effort must be made to ensure that the patient understands the release of responsibility. And it should be emphasized to the patient they can change their mind at any point and signing does not
Witness: The witness must have been present and witnessed the patient’s signature and then fill out the witness to refuse tab which includes their last name; first name and phone number, then obtain the witness’s signature.
Refusal to sign the release of liability: The patient and/or witness also have the right to refuse to sign the release of liability. If this occurs, document the refusal to sign and always offer they can call back if they change their mind.