When a competent patient refuses treatment, what is essential to document?

• A. Informed refusal and capacity assessment
• B. Do not document any reason
• C. Document the refusal but omit capacity
• D. Document only the patient name

Answer: (A)

When a patient is competent and chooses to refuse treatment, you must document that the patient was informed about the risks, benefits, and alternatives, and that an assessment of capacity was conducted showing the patient can understand and make the decision. This reflects patient autonomy and provides legal and medical protection for both patient and providers.

In practice, the record should show that the patient understood the information presented, including the consequences of refusing treatment, and that the patient’s decision was voluntary. Note the specifics of the capacity assessment—whether the patient could understand the information, appreciate the consequences, reason about options, and communicate a choice. Also document the exact refusal as stated by the patient, the time and date, any questions asked and answers given, whether an interpreter or witnesses were involved, and your signature or credential.

Other options fall short because omitting capacity loses essential proof that the patient was truly able to refuse, and documenting only the name or refusing to provide a reason fails to capture the patient’s informed, autonomous decision.