305 – Refusal of Care-Against Medical Advice

MISCELLANEOUS POLICIES MODULE Refusal of Care-Against Medical Advice # 305
2. The following shall be carefully documented on the patient care report:
a. History of the incident, to include the mechanism of injury and time incident occurred.
b. Patient’s chief complaint or concern if called by someone else.
c. Past medical history; meds, allergies, and primary caregiver.
d. Physical exam or any portion of it that was performed, including level of consciousness.
e. Any medical treatment given. Any medical treatment/evaluation needed and refused.
f. The need for transport by an ambulance. Also if transport by means other than an ambulance
could be hazardous due to the individual’s injury or illness.
g. Time the base hospital contact was made and name of person receiving the report.
3. Patient provided with a Refusal of Care (AMA) Information Sheet (see Appendix B). Once patient
signs the form have a witness also sign the form. If the patient refuses to sign the form, document
that refusal in your comments in the patient care record and have a witness also sign the form.
Originated: January 1, 2000 Last Revision: May 29, 2012 Page: 2 of 2