Termination of a Termination of a Provider/Patient Provider/Patient

RelationshipRelationship

Dona Ana Dona Ana County County

Release of Release of Liability Liability

2-16-20112-16-2011

ObjectivesObjectives

1.1. Understand the “why” and the process Understand the “why” and the process behind the termination of a behind the termination of a provider/patient relationshipprovider/patient relationship

2.2. Understand and implement the changes Understand and implement the changes to approach and documentationto approach and documentation

3.3. Establish standards for capacity, Establish standards for capacity, documentation and supervisiondocumentation and supervision

4.4. Apply this policy to scenariosApply this policy to scenarios

The Why: Why are we changing The Why: Why are we changing our current process?our current process?

We have no clear policy on how to terminate a patient relationship

Our system offers little guidance to our pre-hospital personnel

It is necessary to establish and follow a standardized approach to include the process and form

You have an obligation to the agency for which you work

The Why: Where did this policy The Why: Where did this policy come from?come from?

Our policies, a combination of Our policies, a combination of best best practicespractices from other EMS Systems from other EMS Systems across the countryacross the country

Changes were made to adapt to our Changes were made to adapt to our system. system.

The policy and forms have gone through The policy and forms have gone through legal and medical direction reviewlegal and medical direction review

The Why: Review of The Why: Review of Abandonment, NegligenceAbandonment, Negligence

The act of leaving a patient without The act of leaving a patient without treatment or transportation without the treatment or transportation without the patient’s informed consentpatient’s informed consent

Failure to use such care as a reasonably Failure to use such care as a reasonably prudent EMS provider would use in similar prudent EMS provider would use in similar circumstancescircumstances

The Why: Reality CheckThe Why: Reality CheckMost refusals are obtained for non-Most refusals are obtained for non-

eventful situationseventful situationsEMTs are not likely to recall the event or EMTs are not likely to recall the event or

patient years after the callpatient years after the callFailure to document to serve as proof of Failure to document to serve as proof of

the events that day will be very damaging the events that day will be very damaging to an EMT’s defenseto an EMT’s defense

The Why: Another reality checkThe Why: Another reality checkLack of documentation isLack of documentation is

A response to increasing call volumeA response to increasing call volumeNeed for proper medical and legal Need for proper medical and legal

categorization of patients and non-patientscategorization of patients and non-patients

The Process: What has been The Process: What has been changed?changed?

A countywide policy was created A countywide policy was created The “Refusal Form” has been revised – The “Refusal Form” has been revised –

now called the “now called the “Dona Ana County Dona Ana County Release of Liability FormRelease of Liability Form””

The cancellation form/documentation has The cancellation form/documentation has been revampedbeen revamped

The Process: Who is a patient?The Process: Who is a patient?A.A. A person consenting (informed or implied) to assessment A person consenting (informed or implied) to assessment

and/or treatment;and/or treatment;

B.B. Any person having a current history, or perceived or observable Any person having a current history, or perceived or observable condition, of any of the following:condition, of any of the following:

1.1. A physical or psychological complaint;A physical or psychological complaint;

2.2. Altered level of consciousness; Altered level of consciousness;

3.3. Alcohol or drug use; Alcohol or drug use;

4.4. Medical history that has a potential to worsen or complicate Medical history that has a potential to worsen or complicate present condition;present condition;

5.5. A person presenting with an obvious injury;A person presenting with an obvious injury;

6.6. A person suffering from a significant MOI, regardless of A person suffering from a significant MOI, regardless of injury; orinjury; or

7.7. Any patient who has an ambulance summoned on their Any patient who has an ambulance summoned on their behalf AND requires medical assessment and/or behalf AND requires medical assessment and/or intervention. intervention.

The Process: You have a patient The Process: You have a patient relationship. Now what?relationship. Now what?

Consenting, competent adults who allow Consenting, competent adults who allow assessment, treatment and transport, no assessment, treatment and transport, no problem, right? Proceed as usual and problem, right? Proceed as usual and document in a PCR.document in a PCR.

My patient wishes to refuse assessment, My patient wishes to refuse assessment, treatment, transport, or all of the above….treatment, transport, or all of the above….

The Process: Establishing Standards The Process: Establishing Standards for Competency and Capacityfor Competency and Capacity

Competency: Only a judge or physician can Competency: Only a judge or physician can determine whether a person is incompetent.determine whether a person is incompetent.

Capacity: EMTs are required to determine Capacity: EMTs are required to determine whether a patient has the capacity to refuse care.whether a patient has the capacity to refuse care.

To start, a patient must beTo start, a patient must be 18 years old18 years old Alert to person, time, place, events (AAOx4)Alert to person, time, place, events (AAOx4) Have a GCS of 15Have a GCS of 15

The Process: Establishing The Process: Establishing Capacity – a better wayCapacity – a better way

It’s fairly easy to justify taking a sick person to the It’s fairly easy to justify taking a sick person to the

hospital. Justifying why you left them at home takes a lot more hospital. Justifying why you left them at home takes a lot more effort.effort.

Ultimately, the EMT must determine the patient’s Ultimately, the EMT must determine the patient’s ability to comprehend the risks of refusing care ability to comprehend the risks of refusing care and/or treatment.and/or treatment.

AAOx4 is a conclusion. Don’t rely on this alone. AAOx4 is a conclusion. Don’t rely on this alone. How did you get there?How did you get there?

Document the questions and the answers used to Document the questions and the answers used to determine mental capacity/competence.determine mental capacity/competence.

You can use many methods to do so.You can use many methods to do so.

The Process: Establishing The Process: Establishing Standards for DocumentationStandards for Documentation

Best way to complete a refusal is to Best way to complete a refusal is to complete a PCR as if the patient were complete a PCR as if the patient were transported.transported.

Note anything that may affect capacity Note anything that may affect capacity (alcohol, drugs, head injury, blood loss), (alcohol, drugs, head injury, blood loss), MOIMOI

Review DAC Release of Liability Items 1-Review DAC Release of Liability Items 1-1010

The Process: Establishing The Process: Establishing Standards for DocumentationStandards for Documentation

Complete the DAC Release FormComplete the DAC Release FormEnsure items 1-10 are completedEnsure items 1-10 are completedObtain appropriate signatureObtain appropriate signatureObtain witness signature (who witnessed Obtain witness signature (who witnessed

items 1-10)items 1-10)Document items 1-10 in a PCRDocument items 1-10 in a PCR

The Process: Establishing The Process: Establishing Standards for SupervisionStandards for Supervision

Review items 11 and 12Review items 11 and 12Whenever possible, EMTs should ask Whenever possible, EMTs should ask

medical control to supervise a patient’s medical control to supervise a patient’s refusal of transport.refusal of transport.

When do you complete the Against When do you complete the Against Medical Advice section?Medical Advice section?

Arrive on sceneArrive on sceneMake contact with the person to whom you Make contact with the person to whom you

respondedrespondedThe person DOES meet the criteria for a The person DOES meet the criteria for a

patientpatientThe patient refuses transport by EMSThe patient refuses transport by EMSDocument all items in a PCR including that Document all items in a PCR including that

the pt had the capacity at the time of the pt had the capacity at the time of refusal.refusal.

When do you complete the When do you complete the Juvenile/Incompetent/In Juvenile/Incompetent/In

Custody section? Custody section? Arrive on sceneArrive on scene Make contact with the person to whom you Make contact with the person to whom you

respondedresponded The person meets the criteria for a patientThe person meets the criteria for a patient The person is under the age of 18 The person is under the age of 18 OROR The person is considered legally or medical The person is considered legally or medical

incompetent incompetent OROR The person is in the custody of a law enforcement The person is in the custody of a law enforcement

agencyagency Document all items in a PCRDocument all items in a PCR

Review: Emancipated Minors in NMReview: Emancipated Minors in NM

To be emancipated a minor must be at To be emancipated a minor must be at least 16 and least 16 and

1)1)has been married, even if he no longer is;has been married, even if he no longer is;

2)2) is in the active duty military; or is in the active duty military; or

3)3)has been emancipated by the court. has been emancipated by the court.

For example, a 14 year old who is married is For example, a 14 year old who is married is not emancipated. (32A-21-3).not emancipated. (32A-21-3).

Juvenile/Incompetent/In Juvenile/Incompetent/In Custody (cont.)Custody (cont.)

It is not the EMS provider’s responsibility to medically “clear” It is not the EMS provider’s responsibility to medically “clear” persons before they are transported to jail.persons before they are transported to jail.

If contact is made and the patient is not treated or transported, a If contact is made and the patient is not treated or transported, a signed release of liability must be obtained from the patient.signed release of liability must be obtained from the patient.

If the patient refuses or cannot sign because they are handcuffed, If the patient refuses or cannot sign because they are handcuffed, document the verbal refusal and have the police officer witness it.document the verbal refusal and have the police officer witness it.

If the officer is refusing EMS transport for the patient, then that If the officer is refusing EMS transport for the patient, then that officer must sign the refusal as the patient’s guardian.officer must sign the refusal as the patient’s guardian.

As with any refusal, read the appropriate section of the liability As with any refusal, read the appropriate section of the liability release to the patient/officer, document that and their apparent release to the patient/officer, document that and their apparent understanding in the PCR narrative.understanding in the PCR narrative.

In the event we cannot obtain a signature for whatever reason, In the event we cannot obtain a signature for whatever reason, document the “exception” in detail.document the “exception” in detail.

When do you complete the When do you complete the Non-Patient section?Non-Patient section?

If the individual is not a patient, then there was no If the individual is not a patient, then there was no relationship to begin with.relationship to begin with.

Arrive on sceneArrive on scene Make contact with the person to whom you Make contact with the person to whom you

respondedresponded The person does NOT meet the criteria for a The person does NOT meet the criteria for a

patient. patient. Per protocol - see next slide!Per protocol - see next slide! Complete documentation per your agency’s policyComplete documentation per your agency’s policy

Who is NOT a patient?Who is NOT a patient? Non-Patient.Non-Patient. Use this section when a person has NO Use this section when a person has NO

MEDICAL COMPLAINT, INJURY OR ILLNESS. A MEDICAL COMPLAINT, INJURY OR ILLNESS. A person who meets ALL of the following criteria is NOT person who meets ALL of the following criteria is NOT considered a patient if he or she:considered a patient if he or she:

Did not request an ambulance. Calls to 9-1-1 are not Did not request an ambulance. Calls to 9-1-1 are not always intended by the caller to be an ambulance always intended by the caller to be an ambulance request, although an ambulance may be dispatched request, although an ambulance may be dispatched ((i.e.i.e. minor MVAs); minor MVAs);

Presents with NO current physical or psychological Presents with NO current physical or psychological complaints/symptoms;complaints/symptoms;

Has NO signs or symptoms of an active significant Has NO signs or symptoms of an active significant medical illness or injury;medical illness or injury;

Is a legal adult; andIs a legal adult; and Is not under the influence of drugs including alcohol.Is not under the influence of drugs including alcohol.

Who is NOT a patient?Who is NOT a patient? It is up to the EMT to use their:It is up to the EMT to use their:

common sense common sense and good judgment to determine who is a patient and and good judgment to determine who is a patient and

who is not a patient.who is not a patient.

Complete documentation per your Complete documentation per your agency’s policy.agency’s policy.

AMR Non-patient AMR Non-patient documentationdocumentation

A PCR must be completed to account for A PCR must be completed to account for the run.the run.

In the narrative section give a brief In the narrative section give a brief description of the events and why it description of the events and why it qualifies as a non-patient.qualifies as a non-patient.

LCFD Non-patient LCFD Non-patient documentation in Red Alertdocumentation in Red Alert

A PCR must be completed to account for the run.A PCR must be completed to account for the run. Enter required info on a PCR (see video Enter required info on a PCR (see video

In the PCR: In addition to the demographic information, In the PCR: In addition to the demographic information, fill out the required fields:fill out the required fields: Turned over to: Enter “Non-Patient”Turned over to: Enter “Non-Patient” Disposition: Enter “4830” (No treatment Required)Disposition: Enter “4830” (No treatment Required) Condition Code: Enter “-25” (Not Reporting)Condition Code: Enter “-25” (Not Reporting) Location, Symptoms, Provider Impression: Enter “-25” Location, Symptoms, Provider Impression: Enter “-25” C/C: Enter “Non-Patient/No complaint or injury” Use quotes.C/C: Enter “Non-Patient/No complaint or injury” Use quotes. Level of Care for Needed and Provide: “Non-Patient”Level of Care for Needed and Provide: “Non-Patient” Reported Complaint, Location Type, Primary Cause of Injury, Reported Complaint, Location Type, Primary Cause of Injury,

Intend of Injury: “-25”Intend of Injury: “-25”

LCFD Non-patient documentation in LCFD Non-patient documentation in NFIRSNFIRS

NFIRS – Section C Incident TypeNFIRS – Section C Incident TypeUse 322 for an MVA with injuries if there is at Use 322 for an MVA with injuries if there is at

least one patient.least one patient.Use 324 for an MVA with no injuries and all Use 324 for an MVA with no injuries and all

persons at the scene were non-patients.persons at the scene were non-patients.

PATIENT CONTACT DEFINEDPATIENT CONTACT DEFINED

DiscussionDiscussion

Patient contact and Patient contact and cancellationscancellations

The first due FIRE unit arrives on sceneThe first due FIRE unit arrives on scene Makes contact with the person to whom you respondedMakes contact with the person to whom you responded The person meets the criteria for a patient (or non-patient)The person meets the criteria for a patient (or non-patient) Pt does NOT need ALS assessment and the patient refuses/may Pt does NOT need ALS assessment and the patient refuses/may

refuse transport by EMSrefuse transport by EMS Fire unit makes decision to cancel or not to cancel the transport Fire unit makes decision to cancel or not to cancel the transport

agency agency If no pt contact made by transport agency – FIRE gets refusalIf no pt contact made by transport agency – FIRE gets refusal If contact is made by transport agency or pt care is TOT transport If contact is made by transport agency or pt care is TOT transport

agency for whatever reason, agency for whatever reason, transport agency gets refusal transport agency gets refusal documentationdocumentation

First due First due does notdoes not need to get duplicate refusal documentation need to get duplicate refusal documentation First due unit documents in PCR that pt turned over for transport, First due unit documents in PCR that pt turned over for transport,

refusal or unknown dispositionrefusal or unknown disposition

Patient contact and Patient contact and cancellationscancellations

First due TRANSPORT UNITFirst due TRANSPORT UNIT arrives on scenearrives on scene Makes contact with the person to whom you respondedMakes contact with the person to whom you responded The person meets the criteria for a patient or (non-patient)The person meets the criteria for a patient or (non-patient) Pt is assessed and the patient refuses/may refuse transport by EMSPt is assessed and the patient refuses/may refuse transport by EMS Transport unit makes decision to cancel or not to cancel the fire unit Transport unit makes decision to cancel or not to cancel the fire unit No pt contact made by fire unit – TRANSPORT AGENCY gets refusalNo pt contact made by fire unit – TRANSPORT AGENCY gets refusal Pt care should never be TOT from an ALS transport unit to a fire unit for any Pt care should never be TOT from an ALS transport unit to a fire unit for any

reasonreason Fire unit Fire unit does not needdoes not need to get duplicate refusal documentation to get duplicate refusal documentation Fire unit documents in PCR that pt turned over for transport, refusal or Fire unit documents in PCR that pt turned over for transport, refusal or

unknown dispositionunknown disposition

FIRST DUE UNIT CANNOT GET CANCELLED BY SECOND DUE UNITFIRST DUE UNIT CANNOT GET CANCELLED BY SECOND DUE UNITWHY?WHY?

AMR documentationAMR documentation

Continue to use the “cancellation form”Continue to use the “cancellation form”

Complete Quicnet “bubble” formComplete Quicnet “bubble” form

LCFD NFIRS Cancellation LCFD NFIRS Cancellation CodesCodes

You don’t make it on-scene.You don’t make it on-scene. NFIRS 611/Dispatched and cancelled enroute and NFIRS 611/Dispatched and cancelled enroute and NONO patient patient

contact is made; No PCRcontact is made; No PCR You arrive on-Scene and You arrive on-Scene and NONO patient contact is made. patient contact is made.

NFIRS 622/No incident found on arrival at incident address; No NFIRS 622/No incident found on arrival at incident address; No PCRPCR

Medical AssistsMedical Assists 311 with PCR (pt relationship does exist including vitals 311 with PCR (pt relationship does exist including vitals

taken, assisting with pt packaging and loading)taken, assisting with pt packaging and loading) Lift AssistsLift Assists

554 (5-Service call, 55 Public Service Assistance, 554 Assist 554 (5-Service call, 55 Public Service Assistance, 554 Assist Invalid) ORInvalid) OR

321 EMS call excl. accident with injury with PCR if you have a 321 EMS call excl. accident with injury with PCR if you have a patientpatient

Other County Non-patient Other County Non-patient documentationdocumentation

A Patient Care Report must be A Patient Care Report must be completed. completed.

The ROL form must be filled out.The ROL form must be filled out. The data must be entered into The data must be entered into

NMEMSTARS as either a cancelled run or NMEMSTARS as either a cancelled run or no patient found. no patient found.

Other county agencies Other county agencies documentationdocumentation

Continue to fill out the Run formContinue to fill out the Run form

NMEMSTARS entry made for cancellationNMEMSTARS entry made for cancellation

For unusual circumstances…For unusual circumstances…

Call medical controlCall medical control Call your supervisorCall your supervisor Cover your bases:Cover your bases:

Complete the Release of Liability formComplete the Release of Liability form Complete a PCRComplete a PCR Call your supervisor and/or Medical Director for Call your supervisor and/or Medical Director for

additional clarificationadditional clarification

““Nobody will mess you up for doing too much Nobody will mess you up for doing too much documentation.” – Rob Campiondocumentation.” – Rob Campion

Who’s Responsible?Who’s Responsible?

Everyone is responsible.Everyone is responsible. The highest level of provider on scene is The highest level of provider on scene is

ultimately responsible for patient care. ultimately responsible for patient care. Look up state statue Look up state statue

Multiple PatientsMultiple Patients How are MCIs categorized?How are MCIs categorized? Figure out how many people are involved, regardless of Figure out how many people are involved, regardless of

the categorization.the categorization. When it’s all said and done, the transporting agency and When it’s all said and done, the transporting agency and

the fire department should documentthe fire department should document The total number of patients involvedThe total number of patients involved How many were treated by the transport agencyHow many were treated by the transport agency How many were treated by the fire departmentHow many were treated by the fire department How many identified themselves as Non-patientsHow many identified themselves as Non-patients

AMR Record KeepingAMR Record Keeping The DAC Release of Liability Form will replace The DAC Release of Liability Form will replace

the current “refusal” form in circulation.the current “refusal” form in circulation.

A PCR still must be completed in its entirety. A PCR still must be completed in its entirety.

A Quicnet “bubble” form must be completedA Quicnet “bubble” form must be completed

Both forms will be inserted inside the PCR and Both forms will be inserted inside the PCR and then placed in the shift envelope.then placed in the shift envelope.

LCFD Record KeepingLCFD Record Keeping What forms get filled out and what goes What forms get filled out and what goes

where? where? Pt Assessment Forms, Pt Assessment Forms, i.e.,i.e., cheat sheets, will be in cheat sheets, will be in

duplicate – one for us and one for the transporting duplicate – one for us and one for the transporting agency and will be filed as below.agency and will be filed as below.

Completed DAC Release of Liability forms – they Completed DAC Release of Liability forms – they will be single – will be filed in a designated file will be single – will be filed in a designated file folder at the stations to be collected at each station folder at the stations to be collected at each station each week to be filed by the department.each week to be filed by the department.

If any person wishes a copy of a release, direct If any person wishes a copy of a release, direct them to Station 1. them to Station 1.

County Agencies County Agencies Record KeepingRecord Keeping

The new ROL form will replace any refusal The new ROL form will replace any refusal forms in useforms in use

The ROL form will be kept with a copy of The ROL form will be kept with a copy of the NMEMSTARS report, or run form the NMEMSTARS report, or run form currently being utilized by the agencycurrently being utilized by the agency

Each call should generate a run form Each call should generate a run form (paper or NMEMSTARS)(paper or NMEMSTARS)

Each call will be entered into Each call will be entered into NMEMSTARSNMEMSTARS

In a nutshell…In a nutshell… Your interactions will always depend upon Your interactions will always depend upon

your assessment of the scene and/or the your assessment of the scene and/or the patient.patient.

Failure to document those assessments Failure to document those assessments can open the door to claims of can open the door to claims of abandonment or other forms of negligence.abandonment or other forms of negligence.

QUESTIONS?QUESTIONS?