Document the decision, not a label
Show what the patient was deciding, what information they received and the evidence supporting your capacity assessment.
Eight elements
- 1
Decision: Identify the specific care or transport being refused, the time and who participated.
- 2
Assessment: Document primary/secondary assessment, serial vital signs, relevant tests and reversible impairment factors considered or treated.
- 3
Capacity evidence: Record the patient’s own words demonstrating understanding, appreciation, reasoning, communication and voluntariness.
- 4
Information: State the recommendation, material risks, expected benefits, alternatives and uncertainty explained in understandable language.
- 5
Teach-back: Quote or closely paraphrase the patient’s responses; orientation questions alone are not enough.
- 6
Consultation: Record CliniCall/medical oversight, supervisor, receiving clinician, family or substitute decision maker involvement and advice.
- 7
Safety net: Document return precautions, follow-up, supports, access to 911 and the final agreed plan.
- 8
Process: Complete current employer refusal documentation and explain if a signature was unavailable or declined.
Resolved chest pain — refusal of transport
52-year-old man from HOME, lives with spouse and is independent, reports 20 minutes of central chest pressure while walking that resolved before EMS arrival. Denies current pain, dyspnea or nausea. States he does not want transport because he must care for a child at home. History includes hypertension; no prior similar episode.
Primary survey intact. Patient found seated at kitchen table, alert and communicating clearly. Serial vital signs and 12-leads obtained; no recurrent symptoms during observation. BGL and focused cardiovascular/respiratory findings documented. No hypoxia, hypotension, intoxication, acute confusion or other evident reversible impairment identified.
Differential considerations: 1) acute coronary syndrome despite symptom resolution, 2) exertional angina, 3) non-cardiac chest pain. High-risk time-sensitive cause not excluded prehospitally. Capacity assessed specifically for the decision to refuse ED evaluation at this time.
EMS recommended ambulance transport for urgent ED assessment and explained that resolved symptoms and a non-diagnostic prehospital ECG do not exclude myocardial infarction or sudden deterioration. Alternatives and risks, including disability and death, discussed without coercion. Patient used teach-back to explain the concern, recommendation, personal risk and reasons for refusal, communicated a stable voluntary choice and accepted spouse observation. CliniCall/medical oversight and local refusal process completed as required. Return precautions provided. Exact responses, serial findings, consultation, signatures and final disposition documented.