If a patient walking exception is made, how should this be documented?

If a patient walking exception is made, how should this be documented?

• A. Document in the hospital chart
• B. No documentation required
• C. Document the exception clearly in the PCR
• D. Document in the PCR only if transport

Answer: (C)

When EMS makes a walking exception, the official record is the patient care report. That documentation should clearly describe the exception, including that the patient is ambulatory and has chosen to walk to the hospital (or the plan for self-transport), the time of the decision, the patient’s vital signs and condition at the time, any assessment findings, and the patient’s or caregiver’s consent or refusal if applicable. This level of detail ensures continuity of care, communicates the rationale for not transporting by ambulance, and provides a legal record for both patient safety and accountability. The hospital chart isn’t the EMS record and cannot substitute for the PCR, and an exception should be documented even when transport is not performed.

When EMS makes a walking exception, the official record is the patient care report. That documentation should clearly describe the exception, including that the patient is ambulatory and has chosen to walk to the hospital (or the plan for self-transport), the time of the decision, the patient’s vital signs and condition at the time, any assessment findings, and the patient’s or caregiver’s consent or refusal if applicable. This level of detail ensures continuity of care, communicates the rationale for not transporting by ambulance, and provides a legal record for both patient safety and accountability. The hospital chart isn’t the EMS record and cannot substitute for the PCR, and an exception should be documented even when transport is not performed.