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A good refusal narrative should document that multiple alternatives were given. If someone other than the patient is making the refusal decision, that person should be informed of the risks and consequences just as you would inform the patient.
All instances of refusal of treatment must be noted in the patients Health Record. Ideally, the patient should sign a Procedure/ Treatment Refusal Acknowledgement (Patient with Capacity) form. Where the refusal of treatment may lead to harm and/or death, these consequences must be explained and documented.
Documentation should include the following: The patients capacity to understand the information being provided or discussed. Treatment was offered and refused. The reasons a patient refuses a treatment.
All instances of refusal of treatment must be noted in the patients Health Record. Ideally, the patient should sign a Procedure/ Treatment Refusal Acknowledgement (Patient with Capacity) form. Where the refusal of treatment may lead to harm and/or death, these consequences must be explained and documented.
The best way to indicate the right to refuse treatment is to have an advance directive. This document is also known as a living will. Advance directives are kept on file with a hospital.
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DOCUMENTING INFORMED REFUSAL describe the intervention offered; identify the reasons the intervention was offered; identify the potential benefits and risks of the intervention; note that the patient has been told of the risks including possible jeopardy to life or health in not accepting the intervention;
A Patient Care Report (PCR) and a Released at Scene Against Medical Advice Form must be completed for each incident of patient refusal of emergency medical evaluation, care and/or transportation.
They advocate documenting the explanation of the need for the proposed treatment, the patients refusal to consent, the patients reasons, and the possible consequences of refusal.

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