ON OCCASION, YOU MAY ENCOUNTER a patient who refuses or is unable to provide accurate or complete information about his health history, current medications, or treatments. He may be uncooperative for various reasons-for example, he may think too many caregivers have asked him the same questions too many times, he may not understand the significance of the information, he may be fearful or disoriented, or he may be suspicious of why you want him to divulge personal information. Other potential obstacles include severe pain, a psychiatric problem, or a language barrier. In such situations, try to obtain the information from other sources in order to provide him with the best possible care.
Clearly document any trouble you've had communicating with the patient. Record his responses using his own words, plus your interventions or explanations of why you need this information. Document the name of the health care provider you notified about the patient's refusal or inability to share information and the time of notification. Write down other sources of information, such as previous medical records and the patient's other professional caregivers. For example, his primary care provider should have an up-to-date list of his medications, which could be faxed to you. Follow your facility's policies and procedures for handling and documenting these kinds of situations.
A good note might look like this:
11/5/07 0830-When asked for a list of his current medications, pt. said, 'Why do you want to know? What business is it of yours? I don't know why I have to answer that question.'
Explained reasons for needing to know about medications, but pt. still refused to share this information. No previous records available. No family members in to visit pt. Pt. won't share names or telephone numbers of family members. Called Dr. Traynor at 0815 to report pt. failure to provide information. Dr. will speak with pt. on his rounds this a.m. Nora Martin, RN-
Documenting the situation objectively and in the patient's own words when possible protects you by showing that you made every reasonable effort to obtain the information you need to care for him.
Chart Smart: The A-to-Z Guide to Better Nursing Documentation, 2nd edition, Lippincott Williams & Wilkins, 2007.