What should be documented during the refusal process?

• A. The patient’s medical history and allergies
• B. The patient’s orientation, gait, coordination, and speech patterns
• C. The patient’s insurance information
• D. The time of day

Answer: (C)

When a patient refuses recommended care, the focus of documentation is the patient’s informed decision and the communication that led to it. Record that the patient was informed about the proposed treatment, including the risks of proceeding and the risks of refusing, as well as any alternatives that were offered. Document the patient’s actual decision to refuse, the exact treatment or procedure refused, and the reason given by the patient. Note whether questions were answered and the patient demonstrated understanding, along with the time and date, the names or roles of the clinicians involved, and whether a witness or family member was present. Include an assessment of the patient’s capacity to make the decision and any plan for follow-up or re-evaluation if appropriate. This creates a clear, legal record of the refusal and supports continuity of care. Insurance information is administrative and not the clinical basis for documenting the refusal.