Questions

Yes, any statement made by the patient refusing treatment should be documented in writing and added to the patient record. This is an important part of maintaining proper documentation and ensuring the protection of both the patient and healthcare provider. Here's why:

1. Legal Protection: Documenting the patient's refusal of treatment provides legal protection for the healthcare provider. In the event of a dispute or claim, a written record shows that the patient was informed of the treatment options and the potential consequences of refusal.

2. Ethical Responsibility: It ensures that the patient has been informed about the risks and benefits of the proposed treatment and that their decision to refuse is voluntary and informed. It also helps prevent future misunderstandings.

3. Professionalism: Maintaining accurate, thorough records is a professional standard in healthcare, ensuring continuity of care and supporting informed decision-making.

In addition to recording the refusal, it is important to document the information provided to the patient about their treatment options, risks, and any alternatives. Ideally, the patient should sign a document acknowledging their refusal, which becomes part of their permanent patient record.