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Documenting Informed Refusal Effectively The clinicians assessment and recommended treatment; A list of risks and benefits discussed; A list of alternatives discussed; A statement that the patient refused treatment; A statement that the patient had the opportunity to ask questions and a list of any questions asked;
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 patients questions were answered.
Refusal to take medication must be taken seriously, recorded on the Medication Administration Record (MAR), and reported to the manager who may also need to follow up by seeking further advice from a health professional such as the service users GP, pharmacist, or district nurse.
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.
documentation of a patients refusal to undergo a test or intervention should include: an assessment of the patients 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
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A Refusal of Medical Treatment Form is a crucial document in healthcare, designed to document instances where a client or patient chooses to decline a recommended medical procedure or treatment.

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