MVA — Patient Refused Transport, Signed Refusal Form

Clinical Narrative

Unit responded to a motor vehicle accident involving a 45-year-old female who was ambulatory on EMS arrival. Patient reported she was restrained as the driver and vehicle was rear-ended at low speed. Patient complained of neck pain and mild headache rated 3/10. No loss of consciousness reported. Patient was assessed and found to be alert and oriented ×4, GCS 15. Cervical spine precautions were discussed and offered including spinal motion restriction. All vitals were stable throughout assessment. Patient declined transport to the hospital following a thorough discussion of the potential risks of refusing evaluation, including undetected cervical injury. Patient demonstrated understanding of the risks, was alert and competent to make the decision, and signed the patient refusal form. Patient instructed to seek immediate medical attention if symptoms worsened, including increased pain, numbness, tingling, or weakness.

Vitals

Procedures

• Full patient assessment
• Cervical spine precautions offered and discussed
• Vital signs monitoring
• Patient refusal counseling and signed AMA form

Crew & Logistics

Crew

2 personnel, EMT-B

Loaded miles

0

Origin → Dest

S → H

Disposition

refused transport