What must be documented when a patient refuses treatment or transport?

What must be documented when a patient refuses treatment or transport?

• A. Only a verbal refusal is recorded
• B. No documentation is required
• C. Capacity, informed refusal, discussion of risks, alternatives offered, witnesses if possible; obtain signature
• D. Documentation is optional if the patient seems to understand

Answer: (C)

When a patient refuses treatment or transport, you document that the patient had the capacity to make the decision and that the refusal was informed. This means you recorded that the patient understood the risks and consequences of not receiving care, you explained those risks and any alternatives that were offered, and you noted whether a witness observed the discussion if possible. In addition, you should capture the patient’s signature (or a mark) along with the date and time, and identify the provider or agency. If the patient lacks capacity, or if there are other legal considerations (such as intoxication or being a minor without a guardian), you would follow policy instead of recording a valid informed refusal.

When a patient refuses treatment or transport, you document that the patient had the capacity to make the decision and that the refusal was informed. This means you recorded that the patient understood the risks and consequences of not receiving care, you explained those risks and any alternatives that were offered, and you noted whether a witness observed the discussion if possible. In addition, you should capture the patient’s signature (or a mark) along with the date and time, and identify the provider or agency. If the patient lacks capacity, or if there are other legal considerations (such as intoxication or being a minor without a guardian), you would follow policy instead of recording a valid informed refusal.