April 2004, Volume 34 Number 4 , p 79 - 79
© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(4) April 2004 p 79 Documenting refusal of treatment [CHART SMART]
SMITH, LINDA S. RN, MS, DSN
Linda S. Smith is an assistant professor at Oregon Health and Science University School of Nursing in Klamath Falls, Ore.
WITH ONLY RARE EXCEPTIONS, competent adults have the right to refuse treatment, including diagnostic tests and medication. But to avoid legal and ethical ramifications, you must document such refusals properly.
If your patient refuses treatment or medication, your first responsibility is to make sure that he's been informed about the possible consequences of his decision in terms he can understand. If he doesn't speak or understand English well, arrange for a translator. Your documentation in the medical record must include that you and the primary care provider informed him about: ...