What should be documented when a patient refuses treatment?

When documenting a patient's refusal of treatment, it is vital to include the patient's rationale and the actions taken by staff. This comprehensive approach ensures that there is a clear record of why the patient declined the treatment, which is important for protecting both the patient’s rights and the healthcare provider's legal responsibilities. Documenting the patient’s rationale provides insight into their decision-making process and can also reflect their understanding of the treatment and its implications. Furthermore, noting the staff actions demonstrates that the healthcare team took appropriate measures to inform the patient about the treatment, potential risks, and benefits, as well as any support provided. This thorough documentation serves as a valuable record in case of future disputes or questions regarding the patient’s care.