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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.
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.
Documentation should include the following: The patient's capacity to understand the information being provided or discussed. Treatment was offered and refused. The reasons a patient refuses a treatment.
If your patient refuses treatment or medication, your first responsibility is to make sure that he's been informed about the possible consequences of his decision in terms he can understand. If he doesn't speak or understand English well, arrange for a translator.
You should make a record if a patient refuses or withdraws consent. This should include the discussions that have taken place and the advice you have given. If the patient has given a reason you should include this in your notes. However, the patient is not required to give a reason for refusing or withdrawing consent.