Question

You are on a call of a minor vehicle accident. Your patient is a 22-year-old male who was the driver of a moderate T-Bone collision. The patient was not wearing a seat belt and there was spidering of the windshield. The patient complains of neck pain and has a scalp laceration. After performing the primary assessment, you take vital signs and bandage the patient's scalp. When you tell him you need to backboard him, he refuses care and ambulance transport. Because the person is alert and oriented to time, place, and person, you have the patient sign the separate patient refusal form provided by your service. How should you document this incident in your EMS report?
A) No report is needed because the patient refused transport and signed the refusal.
B) You should only document what treatment you performed before the patient refused treatment.
C) You should document everything including all patient care, all of your attempts to persuade the patient to go by ambulance, and who witnessed the patient refusal.
D) You should document your patient care and then simply document that the patient was informed of the risks prior to his refusal. Anything extra is unnecessary and wastes time.

Answer

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