Patient Discharge Information Form

Patient Discharge Information = Form

The EMS Patient Discharge Information form has been designed to be used by EMS= personnel to legally document a variety of situations. This duplicate form consists of a = single page. The front of the page i= s used to describe the situation and the back lists a variety of specific patient instructions by complaint.

The form should be used to document any refusal of care by a patient (complete refusal or refusal of specific aspects of care) and to document the patient &= #8216; guardian’s understanding of medical instructions.

To understand the intent of th= is form, it is simplest to walk through several common patient encounter situations.

= 1.&n= bsp; Complete refusal of EMS care or transportation: T= he first box “Patient Refusal” should be marked. In the first section, the appropri= ate blocks for “paramedic recommendation” should also be marked. This section should be explained t= o the patient or guardian, who should understand that their refusal might result = in complications up to and including death.&n= bsp; The patient or guardian should be asked to sign the form, indicating that he/she understands the seriousness of the situation and the information provided. If the situation warrants, the EMS personnel should expla= in the risks of refusal using the patient instructions section and the back of the form for assistance. If the instructions section is used, the appropriate blocks should also be checked= .

= 2.&n= bsp; Refusal of a specific procedure (IV therapy, for example): The firs= t box “Patient Refusal” should be marked. In the first section, the specific refused procedure should be marked. This section should be explained to the patient or guardian, who sho= uld understand the potential consequences of their refusal. The patient or guardian should be = asked to sign the form, indicating that he/she understands the seriousness of the situation.

= 3.&n= bsp; The box “Patient Instructions” and the appropriate blocks in that section should be marked. This section and the specific instructions (on the back) should all be carefully explained to the patient and/or guardian, who must understand them.= The patient or guardian should be asked to sign the form, indicating that he/she understands the instructions and the seriousness of the situati= on.

In all situations, the top par= t of the form should be completed, and as much of the signature portion as necessary. It is preferable t= o have witnesses, particularly if the patient or guardian refuses to sign. The original form should be kept on file, while a duplicate copy should be provided for the patient or guardian= .