What documentation is required when a patient refuses treatment or transport?

When a patient refuses treatment or transport, it is essential to document the facts about the patient's mental capacity and understanding. This documentation serves as a crucial record that indicates the patient was informed about their condition, the proposed treatments, and the potential consequences of refusing care. It demonstrates that the patient was competent to make an informed decision and understood the risks associated with their refusal.

This process is fundamental to protect both the patient and the healthcare provider from any future legal complications. By capturing the patient's understanding and mental capacity, it shows that appropriate care was offered and that the patient's autonomy was respected. This also helps ensure compliance with legal and ethical standards in emergency medical services.

Documentation of other elements, such as the patient's name and signature, can be a part of this process, but without thorough details regarding the patient's understanding and mental capacity, the record may not sufficiently support the decision-making process involved in their refusal of care.