DOS & DON’TS: [√] Document Worker’s Refusal of First Aid or Medical Treatment

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Most workplaces are required to provided some degree of first aid on site, ranging from providing first aid kits to having trained first aid attendants and fully stocked first aid rooms. The OHS laws require you to keep records of the first aid provided to workers—but you should also document any time a worker refuses first aid or other medical treatment. For example, an injured worker may refuse first aid if he doesn’t think the injury is a big deal. However, even small cuts can become infected if not properly treated and develop into more serious injuries. So if a worker refuses first aid in the workplace or to be sent for more advanced medical treatment, you should document the refusal, noting, at a minimum, the date, type and nature of the injury, its cause, the recommended treatment, the fact the worker refused such treatment and why he refused (if known). You should also have the worker sign the refusal form. Such documentation may be important if the worker later develops complications from the injury or seeks workers’ comp benefits.

An employer in Alberta was glad it had a record of a worker’s refusal of medical treatment. The worker fell while lifting a heavy object at work and injured his back. He went to the onsite health clinic that day, where he was told he had a muscle strain/sprain injury and shouldn’t do any heavy lifting. He called in sick the next day. When the worker came into work the following day, he was offered modified duties, which he refused. He also refused medical services, including treatment or transportation to a hospital. And he signed a form that said, “This is to certify that I, [name] am refusing the medical services (treatment/transport to a hospital) offered by the first aider or medical attendant. I hereby release the medical attendant, the first aider and [the employer] from the responsibility of any medical complications that may occur due to my refusal of medical attention.” The worker filed a claim for temporary disability benefits, which was approved. So the employer appealed.

The Appeals Commission explained that the worker would be eligible to receive benefits if the medical evidence showed that the work-related injury resulted in temporary work restrictions that prevented him from doing suitable employment. Here, the worker prolonged his period of disability by refusing medical treatment and the employer’s offer of appropriate modified employment. By signing the refusal of medical services form, the worker appeared to be taking personal responsibility for obtaining his own medical care to treat his compensable injury. In fact, he told the employer that he intended to see his own family doctor in another city. But there’s no evidence that he sought medical attention from his own doctor until more than two weeks later. In short, the worker’s period of disability was prolonged through his own actions in refusing medical treatment at work and then by not seeking medical treatment in his home location. Thus, he’s not entitled to temporary disability benefits, concluded the Commission [Decision No: 2013-0541, [2013] CanLII 46486 (AB WCAC), July 2, 21013].