Documenting a Patient’s Refusal of Treatment

Every question in this set, with the answer

Use this to review after you finish — or instead of the timed version, if you would rather just read.

1. At 1400, a patient declines a full left-side turn because of left hip pain rated 7/10 but accepts a small assisted weight shift and heel off-loading. PRN analgesia is administered at 1405. At 1435, pain is 3/10 and the patient accepts assisted repositioning. Which entry best distinguishes the initial decision from the care accepted?

   1. 1400: Patient refused repositioning because of left hip pain. 1405: PRN analgesia administered. 1435: Repositioning completed after pain improved.
   2. 1400: Patient declined full left-side turn due to left hip pain 7/10; accepted assisted weight shift and heel off-loading. 1405: PRN analgesia administered; see MAR. 1435: Pain 3/10; accepted assisted repositioning.
   3. 1400: Patient requested pain medication before turning. Repositioning deferred until 1435, when pain was 3/10 and the patient accepted assistance.
   4. 1400: Patient accepted pressure-relief measures after education. 1405: PRN analgesia administered. 1435: Patient repositioned with assistance after pain improved.

   Answer: 1400: Patient declined full left-side turn due to left hip pain 7/10; accepted assisted weight shift and heel off-loading. 1405: PRN analgesia administered; see MAR. 1435: Pain 3/10; accepted assisted repositioning.

   The correct entry separates the full turn initially declined from the alternatives accepted and the later repositioning. The first and third options make all repositioning appear refused or deferred; the fourth omits the specific decision and pain barrier.

2. At 0910, you notify Dr. Chen that a patient declined scheduled enoxaparin because of painful bruising after previous injections. At 0915, Dr. Chen responds with a plan to review prophylaxis options at the bedside; that review is still pending. Which documentation actions keep planned care separate from completed actions? Select all that apply.

   1. Record the 0915 response as a planned bedside review, with follow-up pending.
   2. Enter that Dr. Chen reviewed prophylaxis options at 0915, using the response time as the review time.
   3. Mark the refusal follow-up complete because Dr. Chen has responded to the notification.
   4. Add the outcome of the bedside review when it actually happens.
   5. Leave the planned review out of the record until it occurs so the note contains only completed actions.

   Answer: Record the 0915 response as a planned bedside review, with follow-up pending., Add the outcome of the bedside review when it actually happens.

   Document the response as a plan with pending follow-up, then add the outcome when it happens. Recording a completed review or closing follow-up overstates events, while omitting the plan leaves the next nurse without the continuing plan.

3. At 0900, a patient declines scheduled enoxaparin, reporting painful bruising after previous injections. You review its purpose for blood-clot prevention during reduced mobility and the risk of a clot without recommended prophylaxis. The patient explains the medication’s purpose back to you and continues to decline. Which wording best documents what the patient understood without claiming more than was demonstrated?

   1. Patient educated on enoxaparin and clot risk; verbalized understanding and continued to decline.
   2. Patient understands all risks of declining enoxaparin and refuses because of painful bruising.
   3. Patient explained the medication’s purpose as blood-clot prevention during reduced mobility and continued to decline the dose.
   4. Patient able to make an informed refusal because the medication’s purpose and clot risk were reviewed.

   Answer: Patient explained the medication’s purpose as blood-clot prevention during reduced mobility and continued to decline the dose.

   The correct wording records the specific explanation the patient gave back. “Verbalized understanding” does not show its content, and “understands all risks” exceeds what was demonstrated. Reviewing information alone also does not establish the patient’s ability to make an informed refusal.

4. At 1742, a patient declines to sign the AMA form and continues toward the exit despite being asked to wait for a clinician discussion. The patient leaves at 1744 before that discussion, repeat vital signs, or written instructions can be completed. A callback at 1750 receives no answer. Which documentation choices accurately show what remained unfinished? Select all that apply.

   1. Record that the patient departed at 1744 before clinician discussion, repeat vital signs, or written instructions could be completed.
   2. Chart “Patient refused discharge teaching” instead of describing which activities were not completed before departure.
   3. Chart “Risks explained; patient chose to leave” based on the request to wait for a clinician.
   4. Record the 1750 callback attempt and no answer, without describing instructions as delivered.
   5. Document the unsigned AMA form and departure time without mentioning the incomplete assessment or instructions.

   Answer: Record that the patient departed at 1744 before clinician discussion, repeat vital signs, or written instructions could be completed., Record the 1750 callback attempt and no answer, without describing instructions as delivered.

   The note should identify unfinished activities, and an unanswered callback is an attempt—not completed instruction. Continuing toward the exit does not establish that teaching was specifically refused or that risks were explained. Recording only the unsigned form and departure time hides the remaining gaps.

5. At 1635, you are completing the departure note for a patient who signed an AMA form. At 1615, you were present while Dr. Patel recommended continued evaluation and discussed the risks of leaving; Dr. Patel also assessed decision-making capacity. Which entry best distinguishes the clinician’s work from what you witnessed?

   1. 1615: RN reviewed the risks of leaving and assessed decision-making capacity. Patient continued to request departure.
   2. 1615: Risks of departure reviewed; patient demonstrated decision-making capacity. See provider note for discussion details.
   3. Patient signed the AMA form after risks were reviewed, confirming understanding and decision-making capacity.
   4. 1615: Dr. Patel recommended continued evaluation and discussed departure risks; RN present. Dr. Patel assessed decision-making capacity; see provider note.

   Answer: 1615: Dr. Patel recommended continued evaluation and discussed departure risks; RN present. Dr. Patel assessed decision-making capacity; see provider note.

   The correct entry names who conducted the discussion and capacity assessment while identifying the RN as a witness. The first option wrongly attributes the clinician’s work to the RN, and the second leaves that attribution unclear. The signature does not establish the content of the conversation or substitute for the documented assessment.