MVA, occupants deny injury. How do you document this?

abckidsmom

Dances with Patients
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I'm just curious how y'all would document this:

Vehicle off the road on the interstate in a thunderstorm. Occupants out walking around on arrival, stating they are uninjured. They say they were restrained, describe how the accident happened, and thank you for your time but deny need for EMS.

If you had to pick from this list, which would you choose:

Treated and released
Patient refused treatment
No EMS needed
Standby only

It seems so clear to me that no EMS needed is the right answer, but that one requires name, demographics, full assessment, etc in order to have a "complete" PCR.

I maintain that in order for me to need to document a full patient refusal, you have to be a patient in the first place, which uninjured people are not.

What would you do/say? I am just collected opinions other than my own before I go to address this issue.
 

JPINFV

Gadfly
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What's the definition of a "patient" in your system?

Is someone who neither called EMS nor as any identifiable complaints a patient?

What do you have to document if "no patient is found?"
 

WolfmanHarris

Forum Asst. Chief
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If I have done no assessment I report it as "no patient found" and P&P says I'm supposed to write a report with just run number and times. Usually we record nothing other than the shift log.

If I've actually done an assessment, then I grab a quick set of vitals, record demographics, do the speech about refusing transport and treat it as a refusal. It sucks, but we have little choice with the way the system is designed.

In the middle is a gray area where I may have done a very, very, minimal assessment and still report it as "no patient found."
 
OP
abckidsmom

abckidsmom

Dances with Patients
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What's the definition of a "patient" in your system?

Is someone who neither called EMS nor as any identifiable complaints a patient?

What do you have to document if "no patient is found?"
The wording on "no patient found" in the multiple choice is "patient gone on arrival." Not quite applicable.

We don't have an policy that defines the word patient. That's one thing I hoped to include in this. Do you have a definition for patient? Dictionary.com says "a person who is under medical care or treatment." This could be stretched to include people with a mechanism but without a complaint, I think.
 

ah2388

Forum Lieutenant
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Kind of an odd, although common situation here.

In my mind, it is probably in your best interest to obtain an informed refusal of care, and write it up as "patient refused care"
 

Handsome Robb

Youngin'
Premium Member
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From the choices and the way it works in my system I would pick "No EMS needed"

The way it works where I work is if we mark on scene and make contact with someone involved in the accident but they refuse any care or assessment we do an "Refused Medical Assistance" or RMA if they have no obvious injuries. If they do have obvious injuries and still refuse care it becomes an AMA with or without an assessment.

Mine would look something like this assuming 2 patients since no number was stipulated:

'I arrived on scene to find a vehicle upright and off the side of the interstate in a heavy rainstorm. Both occupants were ambulatory and walking around the vehicle. Both occupants stated they were restrained at the time of the accident. They were able to describe the accident in detail to myself and my partner. Neither had any complaint or obvious injury. Both were found to be alert, oriented, competent and refused any care or assessment from myself or my partner stating "We don't need any help". I explained the risks of refusing a thorough medical assessment after an automobile accident including the possibility of head or spinal injury and the risk that follow these types of injuries up to and including, full or partial paralysis, coma and/or death. Both occupants acknowledged and stated they understood these risk but continued to refuse assessment and care. We advised the occupants of signs and symptoms to watch for and advised them to call 911 if they felt the need. At this time my partner and I returned to our medic unit, unit ### and advised dispatch that we were back in service.'
 

Linuss

Forum Chief
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If they refuse to be checked out, I do "EMS Not Needed", though our PCR doesn't require a full assessment for it. I make sure I notate in the final narrative that the patient refused to be checked out, but I do note how they looked (ventilatory rate can still be counted, skin color assessed, etc)



If I convince them to let me check them out, then it becomes a "Patient Refusal", with the required assessment and demographics.




Is your ePCR something such as the Zoll style? I know at my agency if the ground crews find something we think should be different, all we have to do is fire off an email to our supervisors, and if they agree it should be different, they'll get Zoll to change it. Perhaps you can do the same about "EMS Not Needed"?
 
OP
abckidsmom

abckidsmom

Dances with Patients
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If they refuse to be checked out, I do "EMS Not Needed", though our PCR doesn't require a full assessment for it. I make sure I notate in the final narrative that the patient refused to be checked out, but I do note how they looked (ventilatory rate can still be counted, skin color assessed, etc)



If I convince them to let me check them out, then it becomes a "Patient Refusal", with the required assessment and demographics.




Is your ePCR something such as the Zoll style? I know at my agency if the ground crews find something we think should be different, all we have to do is fire off an email to our supervisors, and if they agree it should be different, they'll get Zoll to change it. Perhaps you can do the same about "EMS Not Needed"?
It's the software offered by the state, that is supposed to meet the minimum data set. The multiple choice language is determined by the state.

So, I looked it up (go figure! Looking it up!) and I was off on what the choices were:

treated and released (full documentation required)
no treatment required (full documentation required)
patient refused care (full documentation required)
cancelled
no patient found

I believe that we could have been covered under any of the last 4.

http://www.nhtsa-tsis.net/ems/state/VA/PPCRTechManNEMSIS[1].pdf

This issue is addressed on page 10 of the pdf.
 

JJR512

Forum Deputy Chief
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Here in Maryland, it the alleged patient is not the person who called 911, and my initial impression is there is nothing wrong with the person, then it's reported as "no patient" and no documentation is needed.

When the incident is an MVC, I would also need to consider mechanism of injury. If there are indicators present (intrusion, rollover, bent steering wheel, etc.) for a significant mechanism of injury, then regardless of how fine (uninjured) the occupants appear and say they are, I can't treat it as "no patient" and I'm supposed to try to persuade them to go by ambulance to a trauma center. They can still refuse, of course, in which case it's documented as a patient refusal. We document what if the patient refuses transportation, treatment, or an exam (any or all of those).

If the patient refuses even just an exam then we indicate we have no vitals or exam findings because the patient refused an exam. In my experience, I haven't seen any patient refuse an exam, but I'm still fairly new at EMS.

Obviously, if the vehicle is merely "off the road" that, by itself, doens't constitute a significant mechanism of injury. It doesn't even indicate an MVC at all, they could have just had a reason to stop and pulled waaaay off the road to minimize the risk of being hit by 80 mph cars on the highway. It actually seems to happen a lot around here that anytime someone is out of their vehicle on a highway, or anytime a vehicle is further off the road than just being on the shoulder, someone driving by inevitably calls 911 to report an accident.
 

VCEMT

Forum Captain
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We just cancel, there's no medical. If fire wants to play, let 'em play. I gotta get back to my nap.
 

shfd739

Forum Deputy Chief
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If there is damage to the vehicle and it was more than a simply driving off onto the shoulder Ill still talk to them and ask to do an assessment. Ill document the findings and that patient reported no complaints along with getting a refusal signed and doing a full report.

Anytime we go onscene with a patient we have to do a full report. Very CYA.
 

jjesusfreak01

Forum Deputy Chief
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If you arrive onscene and the "patient" reports that they did not call 911 and have no complaints or injuries and they will not let you assess them, you have a "no patient found". If they have visible injuries then its in everyone's best interest to try to convince them to let you assess them.

If they have visible injuries, they are technically a patient at that point, however if I was totally unable to assess, i'm probably still going to write it up as a "no patient found", because we can't write up an AMA without demographics. It would be pointless because we wouldn't have any way to follow up and there is nothing legally tying them to our report.

I will write on my NPF reports that the individual for whom EMS was called denied all complaints and does not wish to be assessed.
 

Akulahawk

EMT-P/ED RN
Community Leader
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The way I'd document the run would depend upon specific circumstances. The people involved in the crash may or may not have called 911 to report the crash and have LE come out and take a report, they may have concerns that their vehicle is now a hazard and need Fire to mitigate that hazard... EMS may have been simply called out as part of a standard response to such an event. So, I really don't care who called.

If I have a NPF type of event, I'll document as much as the software will allow. If it's paper-based, then I'll describe the event, number of persons there, all refused exam/care verbally, and attempt to get someone from another agency to countersign my report attesting simply to the above and nothing further. If someone OK's a quick check-out, I'll have to get demographics, document my findings, and either their refusal of care or document as a no identifiable medical need, or something similar. If LE is on scene and the person wants to refuse, LE can simply cancel us on scene prior to patient contact...

There's just so many ways to go at this... Given the lack of choices that abckidsmom posted, if the person wants to refuse all care, including any initial exams, I'd have to go with NPF, with a note that states how many people were found on-scene and that they were advised that if they want EMS, all they have to do is ask... and leave it at that.
 

usafmedic45

Forum Deputy Chief
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Vehicle off the road on the interstate in a thunderstorm. Occupants out walking around on arrival, stating they are uninjured. They say they were restrained, describe how the accident happened, and thank you for your time but deny need for EMS.
In Maryland, it would be documented as "Called for Trooper 2 due to mechanism of injury/damage to vehicle".
 

Handsome Robb

Youngin'
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usafmedic45

Forum Deputy Chief
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It's not really all that funny. One of the two patients died, along with the two EMS providers and the helicopter pilot (a friend of mine).
 

JJR512

Forum Deputy Chief
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The idea that you would say this...
About 10:45 p.m. Saturday, Charles County authorities said, Wells was driving a 2003 Ford Taurus on Smallwood Drive in Waldorf when the car crossed the median, hit several trees, veered into oncoming traffic and collided with a Honda CRX.

Wells and her passenger, Younger, suffered serious injuries. Authorities said yesterday that the accident is under investigation.
(http://www.washingtonpost.com/wp-dyn/content/article/2008/09/28/AR2008092800416.html)
...is the same thing as this...
Vehicle off the road on the interstate in a thunderstorm. Occupants out walking around on arrival, stating they are uninjured. They say they were restrained, describe how the accident happened, and thank you for your time but deny need for EMS.
...and then say this...
In Maryland, it would be documented as "Called for Trooper 2 due to mechanism of injury/damage to vehicle".
...is revolting and in bad taste, especially given the fact that one of your friends was killed.
 

feldy

Forum Captain
391
3
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No Ems if we did not even assess the pt. (we dont have to do a PCR). If we do a quck assessment and pt. does not want to go, its a refusal but we still have to fill out a PCR. If we feel that the pt needs to go and they dont want to, AMA from med control and fill out PCR.
 

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