How should you document a patient's refusal to undergo a necessary intervention?
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Your documentation of a patient's refusal to undergo a test or intervention should include: an assessment of the patient's 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 risks of treatment, and potential consequences of refusal; and a summary of the patient's reasons for refusal (strength of recommendation [SOR]: C, based on expert opinion and case series).
Clinical Inquiries, 2007 (MU)
Journal of Family Practice, 56(12) 2007: 1048-1049.