What should be documented when a patient refuses care?

When a patient refuses care, it is essential to document the patient's capacity assessment and the reasons for their refusal. This documentation serves a critical purpose in ensuring that the healthcare provider has evaluated the patient's ability to make informed decisions regarding their health. The capacity assessment involves determining whether the patient understands the consequences of refusing treatment and can communicate their decision effectively.

Recording the reasons for refusal provides insight into the patient's perspective and any concerns they may have regarding the proposed care. This not only protects the provider legally by showing that the patient was informed and understood their options but also aids in continuity of care if the patient returns for treatment in the future. Proper documentation in these situations is vital to confirm that the patient is making an informed decision and to reflect adherence to medical protocols and legal requirements.