The male person on-scene is complaining of abdominal pain but refuses any treatment or transport going against your advice. He has obvious bruising to his abdomen consistent with a seatbelt injury. Using Queensland Ambulance Service protocols as a guide - discuss what steps you would need to take to ensure you have met your duty of care and that the patient is giving a valid refusal. Include in this task the information you would need to document in your patient care records.

Question

The male person on-scene is complaining of abdominal pain but refuses any treatment or transport going against your advice. He has obvious bruising to his abdomen consistent with a seatbelt injury. Using Queensland Ambulance Service protocols as a guide - discuss what steps you would need to take to ensure you have met your duty of care and that the patient is giving a valid refusal. Include in this task the information you would need to document in your patient care records.

Answer 1

You might want to read the protocols or guidelines:

http://ambulance.qld.gov.au/clinical.html

http://www.paramedichub.com/paramedic-clinical-practice-guidelines-procedures-1/

Answer 2

To ensure that you have met your duty of care and properly document the patient's refusal, follow these steps based on the Queensland Ambulance Service protocols:

1. Introduction and Assessment:
- Introduce yourself to the patient and explain your role as an emergency medical provider.
- Perform a thorough assessment of the patient's abdominal pain and assess any visible injuries, such as the bruising consistent with a seatbelt injury.
- Ask the patient about the nature, severity, and duration of their pain. Take note of any associated symptoms, such as nausea, vomiting, or changes in bowel movements.
- Document important factors such as the patient's level of consciousness and any preexisting medical conditions or medications they may be taking.

2. Provide Information and Educate:
- Explain to the patient the importance of receiving medical care, especially considering the visible injuries and potential internal injuries associated with abdominal trauma.
- Inform the patient about the potential risks and complications of refusing treatment or transport, emphasizing that certain conditions, such as internal bleeding, may worsen over time and become life-threatening.
- Answer any questions the patient may have and address their concerns as best as you can.

3. Informed Consent:
- Ensure the patient is fully informed about their condition, the risks involved, and the recommended course of action.
- Ask the patient if they understand the risks and consequences of refusing treatment and transport.
- Verify that the patient has the mental capacity to make an informed decision. If there are any concerns about their capacity, involve a medical practitioner or seek additional advice.

4. Documentation:
- Accurately record all relevant details in your patient care records. This documentation is critical for legal purposes and continuity of care.
- Include the patient's statements about refusing treatment and any discussions you had, as well as their reasoning for refusing.
- Note any physical findings, such as the visible bruising consistent with a seatbelt injury, to support your assessment and the patient's decision.
- Document any vital signs, such as blood pressure, heart rate, and respiratory rate, to provide a comprehensive overview of the patient's condition at the time of assessment.
- Include time stamps for each documented interaction, ensuring a clear timeline of events.

Remember, while it is your responsibility to do everything within your professional capacity to promote the patient's well-being, if the patient refuses treatment or transport after being properly informed, it is their right to do so. By following these steps and documenting the process thoroughly, you demonstrate your commitment to the duty of care while respecting the patient's autonomy.