Charting Systems and Patient Records · CDA

What should be done if a patient refuses recommended treatment after being informed of risks and benefits?

  1. Record only the treatment suggested
  2. Document the refusal with date and patient statement, and initial
  3. Cross out treatment plan entirely
  4. No documentation is needed
Show answer and explanation

Correct answer: Document the refusal with date and patient statement, and initial

Documenting informed refusal protects both patient autonomy and legal clarity. The refusal, date and patient’s understanding should be clearly recorded.

Difficulty: Medium Question 16 of 20

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