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> refusal of treatment form
refusal of treatment form
Patient Identification
Verify patient’s full name
Confirm date of birth
Check patient ID number
Document contact information
Treatment Information
Specify the treatment being refused
Provide a brief description of the treatment
Note the recommended alternatives
Include potential risks of refusing treatment
Patient Understanding
Ensure patient understands the nature of their condition
Confirm patient comprehends the treatment benefits
Discuss consequences of refusal
Verify that patient has had an opportunity to ask questions
Documentation
Complete the refusal of treatment form
Include date of refusal
Ensure patient signs the form
Obtain witness signature (if required)
Follow-Up Actions
Schedule follow-up appointment (if applicable)
Provide patient with written information about the treatment
Document refusal in the patient’s medical record
Notify relevant healthcare team members of refusal
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