Why Documenting Informed Refusal Is as Important as Informed Consent!

August 29, 2023

Informed consent is a critical first step for any complex medical treatment plan. It’s essential for physicians to have conversations about the benefits and risks of treatment plans to better inform and educate their patients. State laws vary regarding when and how informed consent must be provided and what the informed consent forms look like, so it’s necessary to know the laws and regulations in your state, as well as the rules and processes at your facility.
But what if the patient refuses to consent to the recommended treatment plan? Patients have the right to refuse the recommended treatment, which means the informed refusal process is just as important as obtaining informed consent.
ISMIE offers guidance that provides information about how to conduct informed consent and informed refusal conversations and why both should be documented. These conversations are key to providing safe and ethical patient care, as well as helping reduce medical professional liability risk.
Additional resources are available, including a sample informed refusal form.
For more information, please contact the Risk Management Division by email.
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