What should be included in documentation of a patient's refusal of treatment?
When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment.
When is a refusal of treatment or services considered a refusal?
1) The "Refusal of Treatment or Services" protocol is implemented when an individual's refusal meets a "standard of concern": a) refuses a treatment or service repeatedly and/or b) refuses a treatment or service that has the potential to place the individual at imminent risk to health or safety.
Where should informed refusal be documented?
As with the informed consent process, informed refusal should be documented in the medical record. In the case study, the jury found in favor of the plaintiffs when faced with a deceased patient and an undocumented patient decision of great importance.
Is a patient care report needed for refusals?
In the narrative c. Nowhere; a patient care report is not needed for refusals d. Both A and B 13. d. Both A and B 14. Which of the following BEST describes a repeater? a. A two-way radio that is mounted in a vehicle b. A two-way radio that can be carried on a belt clip c.
When a patient is refusing medical treatment which information should be included in the documentation?
When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment.
How do you document patient refusal in EMS?
Refuses to sign refusal However, you will need to insert in the refusal form that the person refused to sign and what you did to secure the person's signature on the form. Whether or not the refusal form is signed by the patient or the patient's representative, it also should be signed by you and dated.
What should you do if a patient refuses treatment or transport?
If, however, the patient still refuses care or transport, make them aware of all of the risks and rewards of treatment and non-treatment as necessary in implied consent, complete a patient refusal form (usually located on the back of a standard PCR), and obtain the patient's signature.
What are the rules for refusing to treat the patient?
As a rule of thumb, if unnecessary delays in care may cause irreparable harm, physicians can face legal liability for their refusal to treat. If you need urgent medical attention, and a doctor refuses to treat you, you can pursue a medical malpractice suit against the physician and/or the establishment they work for.
What is a patient informed refusal?
Informed refusal is an attempt to balance the provider's duty to care for patients with respect for patient autonomy and patients' right to self-determination—a balance that has been evolving over time and varies among both state statutory and case law.
What can you record on a PCR?
This includes the agency name, unit number, date, times, run or call number, crew members' names, licensure levels, and numbers. Remember -- the times that you record must match the dispatcher's times.
What can you do if someone refuses medical treatment?
What to Do if Your Loved One Refuses to See a DoctorBe transparent and direct. ... Convince them that it's their idea. ... Make it a "double-checkup" ... Make the rest of the day as enjoyable as possible. ... Get someone who is an authority figure to help.
What do you do when the family of a patient refuses to acknowledge the client's condition and treatment plan?
When patients, families disagree on treatment: 6 ways forwardGet to know the patient's family. ... Minimize confusion. ... Help everyone identify their values. ... Encourage the patient to be open. ... Preserve confidentiality. ... Don't hesitate to call in help.
What do you do if a patient refuses to pay?
When a patient fails to pay a balance within a reasonable amount of time – say, three months – begin following up the mailing of a statement with a call from your office. On such calls, be firm but generous: request payment and offer to set the patient up on a payment plan.
What is it called when a patient refuses treatment?
Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.
What is refusal of treatment?
refusal of treatment a declining of treatment; it may be either informed refusal or not fully informed.
Under what circumstances does a health care professional have the right to refuse treatment to a patient?
Patient non-compliance or bad conduct that impedes the doctor's ability to render proper care, or a patient's demand that the doctor engage in care that the doctor believes is fruitless or harmful or exceeds the doctor's own expertise are all valid bases to refuse to treat.
What is the refusal of treatment?
1) The "Refusal of Treatment or Services" protocol is implemented when an individual's refusal meets a "standard of concern": a) refuses a treatment or service repeatedly and/or b) refuses a treatment or service that has the potential to place the individual at imminent risk to health or safety.
What is repeated refusal of a medication?
Repeated refusal of a medication that has the potential for an adverse effect on the individual, i.e. seizure medication, insulin, blood pressure medication, psychotropic medication, etc. Ongoing refusal to follow a recommended diet which could have a serious impact, i.e. diabetic diet, individual with Prader Willi, morbid obesity. ...
What is a refusal to participate in training?
Repeated refusal to participate in training. Refusal to follow safe sex practices. Refusal of C-Pap.
What is a one time refusal?
A one time refusal or occasional refusal of medication. > The occasional refusal of therapy. > Refusal of medical procedures that do not meet recommended standards of care or prevention, i.e. annual audiological, in which the primary care physician feels there in no adverse consequence. > A one time refusal or occasional refusal to participate in ...
When does the team review the status of a project?
The team reviews the status at the next quarterly review.
Who is informed of the outcome of a program?
The Program Director is informed of the outcome.
What is HRC in a case?
The HRC reviews the case and makes recommendations to the individual and team.
What was the issue in the case of the cardiac catheterization?
One of the main issues in this case was documentation. Essentially the case became a debate regarding a conversation with the cardiologist and the patient about whether cardiac catheterization was offered and refused. The physician admitted at deposition that he made a mistake in not documenting the patient's refusal to have a catheterization. However, he was adamant that he did discuss the matter with the patient and the patient refused the procedure.
What age did a patient have a myocardial infarction?
A patient had a long-standing history of coronary artery disease, suffering his first myocardial infarction (MI) at age 47. He had recurrent chest pain a year later and underwent a work up to rule out MI. He was treated medically without invasive procedures. Four years after the first MI, he came to a new cardiologist, the defendant in this case.
What to do when a patient refuses therapy?
Use any community resources available. "Our advice is to use bioethics, social work and psychiatry services early in the process of therapy refusal, especially when the consequences of such refusal are severe, irreversible morbidity or death." (10) Having the patient obtain a second opinion may be effective, as hearing the same concerns strongly voiced by two physicians may convince the patient to proceed.
Why is it important to understand why a patient refuses an intervention?
According to Holeman, understanding why a patient refused an intervention is important because the decision could be irrational or based on misinformation. "An extreme example is a patient with an elevated PSA who refuses a prostate biopsy because he is afraid it would make him sterile. It would be important to address this concern in the discussion because you may be able to overcome it and obtain consent," says Holeman.
What is prudent practice?
Prudent practice involves comprehensive documentation. As with the informed consent process, informed refusal should be documented in the medical record. In the case study, the jury found in favor of the plaintiffs when faced with a deceased patient and an undocumented patient decision of great importance.
Why are some patients unable to make medical decisions?
(4, 6) Other patients may be suffering from impaired decision-making capacity caused by intoxication, hypoxia, sedation, stress, or fever. "Every effort should be made to reverse potential impairments in capacity, to assure that the patient is making the most rational, autonomous choice." (7)
What is informed refusal?
INFORMED REFUSAL. Texas law recognizes that physicians must obtain consent for treatment and that such consent be "informed.". A variant of informed consent is informed refusal, in which a patient refuses treatment after having been informed of the risks and benefits of the intervention. Many physicians associate the concept ...
When a patient refuses medically indicated treatment, should documentation reflect that?
When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment. This documentation would validate ...
What is the reason for refusing a treatment?
The reasons a patient refuses a treatment. The physician held a discussion with the patient and the patient understood their medical condition, the proposed treatment, the expected benefits and outcome of the treatment and possible medical consequences/risks of refusal. Discharge or follow-up instructions.
What should documentation reflect?
In addition, documentation should reflect that the physician attempted to provide the patient with appropriate discharge instructions and follow-up information. Documentation should include the following: The patient's capacity to understand the information being provided or discussed. Treatment was offered and refused.
What should a physician document?
Physicians also should document a patient’s failure to follow advice, take medication or obtain requested diagnostic studies and any other actions a patient fails to take that might contribute to an injury or delay in the resolution of a medical problem.
Does Indiana have informed consent?
Indiana has very specific statutes outlining what creates a presumption of informed consent, but they don't address informed refusal. It is wise to include elements of informed consent in conversations with patients about informed refusal in your documentation. When a patient or the patient's legal representative refuses medically indicated ...
What is confidential nursing?
Confidentiality is regarded as a critical component of good nursing care and reflects the professional responsibility of the nurse to respect a patient’s rights. The Data Protection Act 1998 also governs the protection of patients’ information (OPSI 1998).
Is veracity a problem for nurses?
Veracity may present a dilemma for the nurse since there are times when telling the truth may cause harm to an individual (non-maleficence). Conversely there may be situations where telling a lie may actually do good (beneficence), although this goes against the principle of veracity (Ellis and Hartley 2003).
Can a nurse refuse treatment if he passes the Re C test?
It is a principle of UK law that a competent adult who has passes the Re C test may refuse treatment even if his life depends on it (Dimond 2004).
Do nurses have to maintain confidentiality?
All nurses, including those practicing within the community, have a duty to maintain confidentiality, although it should be acknowledged that there may be certain situations where confidentiality may be breached (Dimond 2000). Confidentiality is regarded as a critical component of good nursing care and reflects the professional responsibility of the nurse to respect a patient’s rights. The Data Protection Act 1998 also governs the protection of patients’ information (OPSI 1998). The nurse should therefore maintain Alistair’s confidentiality unless there is good reason not to do so.
Can a patient refuse to give consent?
The Court of Appeal has stated that provided the patient has the necessary mental capacity (assessed in relation to the decision that has to me made), they can refuse to give consent with or without a reason for doing so. In UK law, the court protects the right of the individual in this regard.