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Title: An analysis of the validity of medical legal documentation in cases where the patient refuses treatment and/or transport
Authors: Spicer, Richard 
Sobuwa, Simpiwe 
Keywords: Refusal of transport;Ethical and legal considerations;Ethical and legal standards;Patient claims;Healthcare providers;Exposure to legal liability;Health services;Refuse treatment or transportation
Issue Date: 2014
Publisher: South African Journal of Bioethics and Law
Abstract: Objectives. We investigated whether patient record forms (PRFs), as currently completed, meet minimum legal standards and provide medicolegal protection to prehospital healthcare providers, and if their qualification levels influence the level of detail recorded in the patient records. Methods. We retrospectively reviewed consecutive case reports at a single centre over a 1-month period for cases in which ambulance crews attended a patient and the patient later refused to accept transportation to a medical facility. Scores were calculated for each case report, based on the number of data fields completed. The scores were compared for variation between qualifications. Results. A total of 5 873 ambulance cases were dispatched during this period. Case reports for refusal of transport (n=229) were reviewed. No case report achieved 100% compliance with legal requirements. There was no statistically significant variation between levels of qualification with regard to improved detail being recorded. Young adults were the most likely to refuse transport. Most of the refusals occurred in the late evening. Conclusion. Refusal of transport and its documentation are poorly understood and practised by prehospital healthcare providers. The implication is that some patients’ rights could potentially be infringed. This could lead to possible grounds for litigation, for which the defence would also hinge on the adequacy of the documentation.
Description: Spicer, R. Sobuwa, S. (2014)."An analysis of the validity of medical legal documentation in cases where the patient refuses treatment and/or transport". South African Journal of Bioethics and Law, [S.l.], v. 7, n. 2, p. 64-68, nov. 2014. ISSN 1999-7639. Available at: <>. Date accessed: 11 Nov. 2015. doi:10.7196/sajbl.311.
Appears in Collections:HWSci - Journal Articles (DHET subsidised)

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