CURED in Practice: Documenting a Legally Defensible Patient Refusal
From the sidewalk, everything looked routine. A bystander flagged down the engine company, reporting that an elderly man had collapsed briefly outside the post office but was now "awake and talking." When the crew arrived, the man was seated on the curb, flushed and winded, but alert. "I just got too hot," he insisted. "I'm fine. I just want to go home."
He allowed the crew to gather his information and take his vitals. His vital signs were borderline. Heart rate in the 40s. BP at 86 systolic. Blood glucose and SpO2 normal. He denied chest pain or shortness of breath but admitted to "feeling weird" before the fall. The patient’s presentation raised concern for a cardiac issue, but he still refused transport. "I've had a long day. I'll just rest at home."
Few situations are more challenging for EMS providers than the medically concerning, legally competent patient who refuses care. As recent (and well-publicized) court cases demonstrate, EMTs and paramedics face increased scrutiny for their patient assessments and their documentation. When providers improperly assess a patient’s ability to refuse care, and fail to sufficiently document the refusal, they open themselves up to significant civil (and possibly criminal) liability. CURED is a helpful tool for effective documentation of refusals.
The CURED Refresher
For those unfamiliar, CURED is an assessment and documentation framework we introduced to help EMS providers navigate patient refusals. The acronym stands for:
- Capacity
- Understanding
- Risks
- Education
- Decision / Documentation
CURED is not just a memory aid. It is a process to help you deliver patient-centered care that balances a provider’s clinical concerns with a patient’s right to make decisions about their medical care. When used correctly, it does more than protect your license; it protects your patient’s right to make an informed decision.
A CURED-Based Narrative Example
Recently, we received a thoughtful inquiry from a quality assurance specialist asking, "Do you have a written example of a narrative using the CURED acronym to guide documentation? Do your crews use a job aid or pick menus to help standardize how patient capacity is documented?"
Let’s revisit our syncopal patient at the post office. Here’s what a refusal narrative might look like using the CURED approach:
Narrative
Upon arrival, found 78-year-old male seated on sidewalk, alert and oriented x4, surrounded by bystanders. Patient reports he "got too hot and sat down." Per bystanders, patient was unresponsive for approx. 30 seconds but regained consciousness spontaneously. Denies head strike, incontinence, seizure activity, CP/SOB, nausea.
Vital signs: HR 44, BP 86/52, RR 18, SpO2 97% RA, BGL 112.
Capacity: I assessed pt’s capacity by asking for basic information, medical history, recall of events, and memory questions. Pt is A/Ox4, recalls events before episode, answers questions appropriately, demonstrates logical reasoning, no signs of intoxication or altered mental status.
Understanding: Patient verbalizes understanding of syncopal episode, potential cardiac etiology, and abnormal vital signs. When asked to explain back the risks, pt states: "I passed out, and it could be my heart. I could pass out again or worse.
Risks of refusing transport are explained multiple times, including repeat syncope, injury, cardiac arrhythmia, and death. Patient verbalizes understanding.
Education was provided on signs/symptoms to monitor. The patient was advised to call 9-1-1 again immediately if his condition worsened. The patient was instructed on a safe way to get home, such as having a family member drive him or arranging a ride from someone he trusts. I assisted the patient in contacting his wife who stated she was coming to pick him up. The patient declined transport by EMS or alternate care. The patient was advised to follow up with cardiology and primary care ASAP.
Decision/Documentation: Refusal signed by patient and witnessed. Pt able to ambulate without assistance, has access to phone and transportation. Medical control (Dr. Smith) consulted and concurred with decision. Patient was not left alone, turned over to wife upon her arrival on scene.
Should You Use Pick Lists or Templates?
Most electronic health record systems include charting tools like pick lists or templates, which could be used for CURED documentation. Should providers be using these tools for documenting refusals? The short answer: yes, but with caution.
Some systems allow providers to use structured refusal documentation tools, but these tools should never replace thoughtful, individualized narratives. Templates are helpful as reminders but should never replace provider judgment. Your documentation should be tailored to the patient and not simply dropped in with a click. Detailed documentation helps to defend a contested case.
Job Aids for the Field
If you’re looking to build a simple field job aid or update existing protocols or policies regarding refusals, we recommend:
- Use a one-page laminated card or digital reference
- Include the full CURED acronym with examples under each letter
- Add narrative starters like: "Patient demonstrates understanding by stating…" or "Patient’s reasoning appears impaired because…"
Some agencies even require a brief CURED review with medical control during high-risk refusals, a practice that protects the provider and encourages shared decision-making. We recommend this approach.
Final Thought
A patient’s signature on a refusal form doesn’t protect you. Your narrative does. Before your patient signs, make sure they’re CURED, and make sure your chart reads like you actually cared.
Thanks to the QA professional who prompted this critical follow-up. If you’re reading this article and are building similar tools for use in your agency, reach out. We’re stronger when we share.
