EMS Non-Transport/Refusal of Care Report

Date/Time: [Date and time of encounter including time zone]
Agency/Unit: [Agency name]; [Unit identifier] — [Crew members and credentials]
Incident #: CAD [CAD number]; ePCR [ePCR number]
Response Priority: [Dispatch priority]
Location: [Exact address or location description]; [Scene type]
Key Times: Dispatch [time]; Arrival on scene [time]; Patient contact [time]; Departed scene [time]

Patient Information

Patient: [Full name] (If patient declines to provide identifying information, document "Patient declined identifying information" with permitted descriptive identifiers)
DOB/Age: [Date of birth or estimated age]
Sex: [Sex]
Contact: [Phone, address, or preferred contact method] (If unavailable, state why)
Alternate Decision-Maker: [Name, relationship, basis for decision-making authority, and verification method] (Include only if decision-maker is not the patient)
Language/Communication: [Primary language and communication needs] (If interpreter used, document name/ID and modality)

Dispatch and Chief Complaint

[Dispatch reason and caller type; chief complaint in patient's own words when feasible; mechanism of injury for trauma or onset context for medical complaints] (1–3 sentences)

Scene and History

[Scene conditions relevant to clinical risk, refusal, or safety decisions including hazards, living conditions, access issues, law enforcement presence, or environmental factors; collateral historian reports with source identified]

History of Present Illness: [Onset, provocation/palliation, quality, region/radiation, severity, time course as applicable; pertinent negatives relevant to transport decision] (If history cannot be obtained, explicitly state why)

Relevant History: [Pertinent medical/surgical history]; [Medications with focus on anticoagulants, insulin, opioids, sedatives]; [Allergies]; [Baseline cognitive or functional status if relevant]

Assessment

Primary Survey and General Appearance: [Airway, breathing, circulation, disability, exposure as assessed; general appearance, work of breathing, skin signs]

Vital Signs: [BP, HR, RR, SpO2, temperature if relevant, pain score] (Repeat vitals with timestamps if clinical concern exists, treatment given, or prolonged scene time)

Mental Status and Neurologic Assessment: [Level of alertness; orientation details beyond A&Ox4; speech coherence; attention and ability to follow conversation; GCS if applicable; focal neurologic findings] (Document objective observations; this section is critical for refusal documentation)

Focused Physical Exam: [Findings by system examined] (Document only systems actually examined; if exam limited by refusal, document what was attempted, what was refused, and observations made without contact)

Clinical Impression

[Working impression]; [Acuity assessment]; [Why evaluation/transport was or was not recommended]; [Key red flags present or absent that informed recommendation]

Decision-Making Capacity Assessment

(Required for all refusals; support each element with observable facts, direct quotes, or teach-back responses)

• Communicates a Choice: [Description of consistent decision expressed]
• Understands: [Evidence patient demonstrates understanding of recommended evaluation/treatment/transport and rationale]
• Appreciates: [Evidence patient acknowledges how risks apply to their specific situation]
• Reasoning: [Rational explanation aligning with stated goals/values]

Capacity-Affecting Factors: [Suspected intoxication, head injury, hypoxia, hypoglycemia, acute psychiatric symptoms, language barrier, baseline cognitive impairment vs. acute change, or other factors with objective findings described] (If no concerning factors, state "No factors identified that impair capacity")

Escalation: [Medical control, supervisor, law enforcement, or crisis team consulted; time of contact; recommendations and outcome] (Include only if capacity was uncertain or high-risk refusal)

Informed Refusal Process

1. What Was Offered: [Evaluation components, treatments, and/or EMS transport offered]
2. Risks and Benefits Explained: [Benefits of transport/evaluation in plain language]; [Risks of refusing including potential life/limb threats when applicable]
3. Alternatives Discussed: [Options actually discussed: EMS transport, self-transport, follow-up with PCP/urgent care, remain with monitoring]
4. Patient's Decision: [Stated understanding and final decision with direct quote when possible; any partial refusals; persuasion attempts made; patient informed they may call 911 again at any time]

(If patient refuses even evaluation: document that assessment and transport were offered, what patient would and would not allow, what was observed, and that risks were explained despite limited assessment)

Treatments Provided

[Interventions performed: assessments, oxygen, glucose check, medications, wound care, ECG, etc. with dose/route/time and patient response]; [Reassessments after treatment with times]; [Treatments offered but refused with stated reason if provided] (If no treatment provided, document whether not indicated, refused, or unable due to safety)

Disposition

Category: [Patient refused evaluation/care / Patient treated and released / Patient evaluated with no treatment/transport required / Released to law enforcement / Self-transport / Canceled–no patient found]

Post-Departure Status: [Who remained with patient: family, caregiver, facility staff, or no one]; [Patient's stated plan for destination and method of travel]; [Safety concerns identified and mitigation steps taken]

Law Enforcement Release: [Officer name, badge, agency accepting custody; custody status; belongings/medications handoff] (Include only if released to law enforcement)

Self-Transport: [Driver identity and competence; impairment cautions discussed] (Include only if self-transport disposition)

Canceled/No Patient Found: [Reason for cancellation; search area canvassed; attempts to locate or contact patient; notifications made] (Include only if applicable)

Instructions and Return Precautions

Return Precautions: [Specific symptoms/signs that should trigger immediate 911 call or ED visit] (Provide condition-relevant triggers, not generic phrasing)

Follow-Up: [Recommended follow-up destination/provider and timeframe]

Cautions: [Medication effects or impairment cautions such as no driving, avoid alcohol] (Include only if applicable)

Delivery: [Verbal / Written / Both]; [Given to patient / caregiver]; [Interpreter used if applicable]

Consultations and Notifications

Online Medical Direction: [Time contacted; clinician name/service; summary of recommendations] (Include only if consulted)
Supervisor: [Name and guidance provided] (Include only if involved)
Law Enforcement: [Agency, role on scene, case number if provided] (Include only if involved)
Mandatory Reporting: [Concern reported; agency notified; time and reference number] (Include only if applicable)

Signatures and Witnessing

Patient Signature: [Obtained electronic / Obtained paper / Refused / Unable] (If refused or unable, document reason)

Witness Signature: [Name and role] (Non-crew witness preferred; if unavailable, document why and alternative verification used)

Patient Left Prior to Signature: [Attempts made; last known direction of travel; time] (Include only if applicable)