Informed Decision Making Refusal of Care Form

INFORMED DECISION MAKING REFUSAL OF CARE FORM

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Patient Name D.O.B. CAD #

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Patient Address Social Security Number Physician

A. LEGAL CAPACITY

If the answer to at least one of these questions is “YES,” the patient may sign this form. If “NO” to all, the signature of a legally authorized decision maker is required.

Is the patient over 18? yes no If a minor, is the patient married? yes no If a minor, is the patient emancipated? yes no

Comments/Quotes/Observations:______

B. MENTAL CAPACITY

If the answer to any question in part ‘B’ is “YES,” the patient may lack the capacity to refuse care, though this is a fact-specific determination and consultation with medical control is encouraged. Do not release patient or allow to sign this form unless an explanation is noted, or, if the patient is less than 18 years of age a parent or legal guardian signs the form. Any yes answers require consultation with medical control.

Disoriented to: Person? yes no Possible ETOH/drug use? yes no Odor of ETOH? yes no

Place? yes no Admitted by patient? yes no Unsteady gait? yes no

Time? yes no Slurred speech? yes no

Comments/Quotes/Observations:______

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C. MEDICAL CAPACITY

If the answer to any question in part ‘C’ is “YES,” the patient may lack the capacity to refuse care, though this is a fact-specific determination and consultation with medical control is encouraged. Do not release patient or allow to sign this form unless an explanation is noted, or, if the patient is less than 18 years of age a parent or legal guardian signs the form. Any yes answers require consultation with medical control.

Head Injury? yes no ALOC? yes no Abnormal Glucose? yes no Reading:______

Abnormal pupils? yes no Severe Dyspnea? yes no Abnormal SaO2? yes no Reading:______

Comments/Quotes/Observations:______

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D. MEDICAL CONTROL (if required)

Physician Name: ______Contacted by: Phone Radio On Scene

Orders: Release Patient Use reasonable force/restraint to: treat transport

Comments/Quotes/Observations:______

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E. DESTINATION / DIVERT

Diverted by:______Diverted to:______

Reason:______

F. Provider Signature:______