Patient Refusals: Part 1. Incomplete Patient Assessment: The Most Common Risk to the Patient, EMS Provider, and Agency

The Most Preventable Dangerous Call in EMS?

By Paul Girard & Kevin Kelley

Every patient refusal stands or falls on one foundational question:

Did EMS complete and document a sufficient assessment before accepting the refusal?

When refusals are later scrutinized by a medical director, OEMS, DALA, or a court, incomplete assessments are the most common and most damaging failure. They undermine capacity determinations, hollow out risk explanations, and leave the PCR unable to support the decision to leave a patient at home.

A patient refusal without a complete patient assessment is not a refusal at all.  It is a marginally documented patient encounter with a signature attached.

If the assessment is thin or missing, reviewers reasonably conclude that the provider could not have known enough to:

• evaluate capacity,
• explain risks meaningfully,
• recommend transport appropriately, or
• accept an informed refusal.

When the chart does not show what you assessed, the assumption is simple: you didn’t assess it.

What the data suggests

A review of 40,000 patient refusal PCRs reviewed by Girard & Associates over the past several years shows 35% of patient refusals lack documentation specificity required to meet the standard for proper refusal documentation. For transports, incomplete documentation errors were 17%. The calls more likely to get providers into trouble have double the error rate for proper documentation.

At a minimum, a defensible refusal assessment includes:

• Chief complaint and history, including onset, severity, duration, and progression
• Mental status, described not just checked
• Focused physical exam tied to the complaint
• A thorough secondary exam when the presentation warrants it
• Clinical impression, stated plainly in the narrative
• Vital signs are vital evidence that protect the patient, provider, and agency
• An assessment thorough enough to ensure potential differential diagnosis’ have been considered so the patient can be properly informed of all the risks

At least one complete set of vital signs is generally mandatory in every refusal and obtaining more than one set is best practice. Serial vital signs demonstrate that the assessment was deliberate and thorough, and they often reveal changes in a patient’s condition while EMS is still on scene and able to intervene. Trending vitals can also be a powerful patient-education tool; showing a patient how their blood pressure, heart rate, oxygen saturation, or glucose is changing over time can help them understand that something may be wrong and why further evaluation is recommended.

Refusals documented with no vital signs or only a partial set leave providers without the physiological data needed to assess stability, determine capacity, or meaningfully explain risk.

Without that data, EMS is far more likely to miss a serious underlying condition and far less able to defend the decision to leave the patient at home.

Refusals often fail because providers complete either a focused exam or a secondary exam, but not both. In higher-risk presentations falls, dizziness, weakness, syncope, or balance disturbances (as well as other conditions in many cases) both are necessary to reduce what is hidden below the waterline: What is hidden beneath the tip of the iceberg?

Why a Full Assessment Matters More Than It First Appears

Patients who refuse often present in ways that feel deceptively benign. A patient who fell and “just feels a little off,” or who reports dizziness that has “mostly resolved,” can easily be underestimated without a thorough assessment.

In these cases, the differential diagnosis may include stroke, hypoglycemia, arrhythmias, syncope, intracranial pathology, or other serious medical conditions. Without a complete assessment, particularly a secondary exam, it is impossible to know whether additional red flags were present but undocumented.

Incomplete assessments frequently omit critical context, such as:

• whether the patient has had similar episodes before,
• what brought the symptoms on,
• what relieved or worsened them,
• whether there was pain, radiation, or neurologic change, and
• how long the symptoms lasted.

When this information is missing, reviewers are left to assume it was never explored.

Why Incomplete Assessments Become “Normal”

Incomplete assessments on refusals can be the result of laziness or indifference. More often, they arise from predictable human and system pressures, particularly normalization of deviance.

Studies have shown that in the airline industry for example, most plane crashes happen when multiple small, relatively minor issues crop up that go unrecognized for their potential importance. The cumulation of those smaller errors can lead to tragedy. The small problems cascade to the point of critical failure and only in hindsight do people realize the significance.

Nothing bad happens until one day, something does.

Refusals are especially vulnerable to this drift because patients are often awake, talking, and eager for EMS to leave; calls occur late at night or under system pressure to clear; and adverse outcomes frequently occur hours or days later, outside the provider’s line of sight. If the provider does not know that the patient later had a bad outcome, it reinforces their erroneous belief that how they acted was reasonable and repeat the same behaviors.

Over time, the internal benchmark for what constitutes a “reasonable assessment” quietly shifts downward.

The Capacity Problem You Can’t Solve Without Assessment

Capacity is not a feeling; it is a conclusion drawn from evidence. In Massachusetts, STP 7.5 requires that the patient be oriented, unimpaired, and able to understand their condition and the risks of refusal.

You cannot determine capacity without an assessment that demonstrates and considers:

• Baseline and current mental status,
• Physiologic stability (or instability), and
• The absence of conditions that impair judgment, such as hypoxia, hypotension, intoxication, head injury, infection, or metabolic derangement.
• Cultural issues such as language barriers or cultural differences to how people perceive a medical problem, the health care system and even the credibility of the EMS providers as compared to their cultural “norm”.
• The reasons why the patient may be resistant to assessment, treatment, or transport.

Generic statements like “A&O ×4” are conclusions, not evidence. It is not good enough to state the patient is A&O x4, without further description of the patient’s ability to fully understand the implications of refusing. Reviewers expect to see how you know the patient understood what they said, how they reasoned, and how they responded to risk explanations. Without assessment data, those conclusions are unsupported.

“Patient Refused Assessment” Is Not a Shield

Patients may limit assessment. That does not eliminate the obligation to assess. In fact, patient assessment starts the moment you walk in the door and have eyes on the patient. Patient assessment details can be obtained by simple observation of the patient, and that data needs to be recorded. How does the patient look generally? Are they mobile, speaking with anyone? Do they have a steady gait? Do they appear neurologically intact on visualization? Do they appear to be in distress? Respiratory difficulty or difficulty focusing attention? The list goes on.

When parts of an assessment are declined, the PCR must document:

• what was attempted,
• what was explained,
• why the assessment mattered,
• what the patient declined, and
• how those limitations affected clinical judgment,
• what efforts the provider took to try to convince the patient to be assessed, treated and transported.

Generalized statements such as “patient refused all assessment” or “patient was explained all risks of refusal” undermine credibility because they provide conclusions without context. A defensible chart shows effort, explanation, and patient response not resignation.

Assessment Is the Foundation of Risk Explanation

Risk explanations cannot be meaningful without assessment data.

You cannot credibly explain the risks of refusing transport if you do not know whether the patient is hypoxic, hypotensive, tachycardic, neurologically intact, or metabolically stable. Without that information, risk discussions devolve into boilerplate, which reviewers routinely discount.

Patient Assessment drives specificity.  Specificity drives informed patient refusals.

A defensible refusal requires that the PCR clearly show:

• what was assessed,
• what was found,
• what concerns were identified,
• what recommendations were made, and
• why the patient was left at home.

Strong assessments are not about checking boxes. They are about protecting patients and protecting providers when outcomes are uncertain and scrutiny is inevitable.

Here is the bottom-line:

If you didn’t completely assess the patient, you couldn’t have properly explained to the patient the risks for refusing assessment, treatment and transport.

If you couldn’t explain the risks to the patient, the refusal wasn’t informed.

And the patient, EMS provider, and EMS agency are at risk of a bad outcome.  Preventable bad outcomes create risk to the EMS providers Life, Liberty, and Pursuit of Happiness,

Coming up next in this 7-part Patient Refusal series: The Risk of Missing or Forged Witness Signatures

You can also check out our introductory article on this topic: Patient Refusals: A Risk to an EMS Providers Life, Liberty, and Pursuit of Happiness

Or our related article: Preventing the Provider Induced Patient Refusal (PIPRs)

For more information, you can visit our website at www.girardassoc.com.

The authors can be reached at paul.girard@girardassoc.com or kevinkelleylaw@gmail.com.

About the Authors

Paul Girard, a retired paramedic and EMS Director, is the Founder and President/CEO of Girard & Associates, Inc., a national EMS clinical quality improvement consulting firm. He has worked in EMS continuous quality improvement since the mid-1980s and founded Girard & Associates, Inc. in 2005 to help EMS agencies better monitor, evaluate, and improve the patient care they provide.  An EMS CQI entrepreneur, Paul invented and utilizes a proprietary scoring and rating system that drives a teaching, coaching, and mentoring-based CQI process, supporting providers in strengthening clinical judgment, documentation quality, and professional performance. The firm delivers CQI auditing, program development, and CQI program administration for EMS agencies nationwide. Paul is also the co-host of “The G&A Way EMS CQI” podcast.

Kevin J. Kelley, Esq. began his EMS career in 1986.  A retired paramedic and EMS Director turned attorney in 2004, Kevin is the founder of Rescuing Rescuers, PLLC, a Massachusetts law firm dedicated to representing firefighters, EMTs, paramedics, and other licensed healthcare professionals. His practice focuses on EMS license regulatory defense, on- and off-duty criminal and self-defense matters, clinical documentation risk assessment, and firehouse EMS-focused education designed to strengthen patient safety, provider decision-making, and professional defensibility before DPH/OEMS, Division of Administrative Law Appeals, and civil and criminal courts.  Kevin is also the co-host of “The G&A Way EMS CQI” podcast.