What should be included in the PCR when documenting a refusal?

Including details about the patient's understanding of their condition and the consequences of refusing treatment in the PCR (Patient Care Report) is essential for several reasons. This documentation highlights the patient's capacity to make an informed decision regarding their care. It serves as a record that the patient was provided with the relevant information about their medical situation, the implications of refusing treatment, and any potential risks involved. This is crucial in protecting both the patient and the EMS personnel, as it demonstrates that the patient was fully aware of what they were declining and the possible outcomes of their decision.

This careful documentation is vital not only for legal reasons but also for ensuring continuity of care. Should the patient decide to seek medical help later, healthcare providers will have a clearer understanding of the patient's previous interactions and decision-making processes. This contributes to better overall patient care and safety.