oa South African Journal of Bioethics and Law - An analysis of the validity of medical legal documentation in cases where the patient refuses treatment and/or transport

Volume 7, Issue 2
  • ISSN : 1999-7639



We investigated whether patient record forms (PRFs), as currently completed, meet minimum legal standards and provide medico-legal protection to prehospital healthcare providers, and if their qualification levels influence the level of detail recorded in the patient records.

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.
A total of 5 873 ambulance cases were dispatched during this period. Case reports for refusal of transport (=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.
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.

Loading full text...

Full text loading...


Article metrics loading...


This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error