The documentation should include when and where the discussions occurred; who participated or was physically present during the conversations; the options, risks, benefits, costs, and possible outcomes addressed; and notations that the patient's questions were answered.
DOCUMENTING INFORMED REFUSAL A signed refusal for heart catheterization — including the risks, benefits and options, with the patient's signature witnessed — may have prevented this claim. "All cases of informed refusal should be thoroughly documented in the patient's medical record.
Informed refusal may indicate that you and the patient have different values and expectations. Consider whether it would be best if that patient is dismissed from the practice and referred to another dentist. Example: the patient who refuses a radiograph you believe essential to proper diagnosis and treatment.
Be Honest and Direct: Explain your reasons for wanting to refuse the treatment. You might say something like: - ``I've been thinking about the crown treatment, and I've decided I would like to withdraw my consent. I appreciate your recommendation, but I have some reservations.''
Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.
In its most basic terms, informed consent is the conversation during which the dentist gives the patient information about: Any dental health problems that the dentist observed. The nature of any proposed treatment. The potential benefits and risks associated with that treatment. Any alternatives to the proposed ...
You can decline anything you wish. The dentist can't force you to do anything against your wishes. Also, with out proper x-rays, the dental office has the right to decline care.
A record of the patient's refusal of the treatment/testing plan or advice. In this circumstance, consider asking the patient to sign a specific refusal form.