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Discuss the available treatment options along with the associated benefits, risks, anticipated costs, and short-term and extended prognoses. Finally, outline the consequences of failing to undertake any treatment. Provide the opportunity for patient questions to be asked and answered.
Your documentation of a patient's refusal to undergo a test or intervention should include: an assessment of the patient's competence to make decisions, a statement indicating a lack of coercion; a description of your discussion with him (or her) regarding the need for the treatment, alternatives to treatment, possible ...
Documentation of a refusal should also include the following notations in the patient's record: Information the provider gave to the patient concerning the patient's condition and the proposed treatment or test. Reasons for the treatment or test should also be noted.
When that happens, carefully document the refusal and inform the patient of the potential health issues involved because treatment was refused. Document the discussion, the reasons for the refusal and the patient's understanding of those issues in the chart or in an informed refusal form.
Your dentist should: explain the benefits and drawbacks of any treatment they recommend. explain alternatives that may be available. have your permission before they treat you - you can refuse treatment if you do not want it (although if your dentist considers you need it they may refuse to continue treating you)