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The Ambulance Driver's Perspective
by Kelly Grayson

Can they really refuse your care?

Remember when you're documenting a refusal, you're writing a report not for other medical professionals, but for 12 people who didn't know how to avoid jury duty

By Kelly Grayson

Awake, alert and oriented.

Three words you'll find liberally salted throughout EMS run reports and medical charts, used to describe a patient who is lucid and aware of his surroundings, and capable of making informed decisions about his care. Three words so ubiquitous that they've become jargon; accepted nomenclature used without a second thought in thousands of reports every day.

They're also three words that can get you successfully sued, particularly when your patient has refused care.

Keep in mind that when you're documenting a refusal, you're writing a report not for other medical professionals familiar with your jargon, but for twelve people who didn't know how to avoid jury duty. Any semi-competent attorney can shred a statement like "awake, alert and oriented," and in so doing, make you look like an ignorant or lazy provider in the process.

What most EMTs fail to realize is that the shorthand "AAOx4" is a conclusion. A lawyer would phrase it as a conclusion based upon facts not in evidence, and if you didn't include those facts in your documentation, the jury doesn't get to hear them.

A better, more legally defensible, approach would be to document the questions and answers used to determine present mental capacity, and let the jury draw its own conclusion. If they need help drawing that conclusion, that's your attorney's job, and his argument can be made from those statements documented right there in your report.

There are numerous scientifically validated tests out there to determine present mental capacity. The most common, the Folstein mini-mental exam, is a 30-point questionnaire designed to test for cognitive impairment. The exam itself and scoring system is copyrighted, but its elements can be easily adapted for EMS use.

Determination of present mental capacity hinges on three elements: memory, orientation and cognitive ability. A few simple mental exercises, and documentation of the patient's answers, can do far more to demonstrate the patient's capacity to refuse care than simply concluding AAOx4.

Memory
Begin by asking the patient to memorize a short sequence of words or phrases — "Horse, apple, car, television," — and telling them they will be asked to recall those phrases later in the exam.

Orientation
Don't write down the conclusion, write down the questions asked and answered:

When asked if she knew where she was, patient correctly stated that she was in her living room at 1234 Anywhere Lane. When asked for her demographic information, patient was able to correctly state her name, birth date and social security number without hesitation. When asked for the time, patient stated that she did not know, but looked at her watch for reference, and stated the correct time. When asked if she remembered what had happened, patient states she does not remember the event itself, but states that her family told her she had fainted. When asked to identify the family member who told her this, patient correctly pointed to her granddaughter, and said, "Mary." On further questioning, patient was able to identify and name her children and grandchildren, both those present in the room and those not.

Cognitive ability
Ask the patient to do a simple mental exercise, such as calculating the value of a coin combination or repeating the Serial Sevens:

When asked if patient could calculate the value of three quarters, two dimes, two nickels and six pennies, patient correctly stated, "One dollar and eleven cents."

or

When asked to count backwards from 100 by sevens, patient was able to reach 51 without error, and was told by EMTs that was sufficient.

Recall
When asked to recall a series of words provided five minutes earlier — "horse, apple, car, television" — patient was able to correctly recall the words, but repeated them out of sequence.

The results of these simple tests may yield proof of sufficient present mental capacity. A perfect score isn't essential, but keep in mind that the more correct answers you can document, the more weight your refusal will carry.

Remember that documenting present mental capacity is only half the job. You still have to document that the patient was aware of the potential consequences of the refusal, and how you made him aware of those consequences. If this seems like a great deal of extra work for a simple refusal of care, remember that refusals rank second only to ambulance accidents in frequency of litigation against EMS providers.

It's fairly easy to justify taking a sick person to the hospital. Justifying why you left them at home requires a lot more effort.

About the author


Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (www.facebook.com/theambulancedriverfiles), or email him at kelly.grayson@ems1.com.

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