How to Document Patient Refusal of Care: Assessment, Communication and Follow-Up
The short answer
A person with capacity has the right to refuse care. Documentation does not argue with the refusal; it records that an offer was made, that the person was informed, what they said, what you did next and who you told. The College of Nurses of Ontario (CNO) consent guideline notes that consent can be withdrawn at any time and that clients retain the right to refuse treatment.
What to record
- What was offered: the specific care, medication or test, and when.
- The patient's response, in their own words where you can: "I do not want it now."
- The reason they gave, if any, without guessing about motives.
- Information provided about what the care is for and the possible consequences of declining, as appropriate to your role, and whether the person seemed to understand.
- Capacity concerns: if you doubt that the person understands, do not simply document and move on. Tell the responsible nurse or prescriber per your policy.
- Alternatives offered and the response.
- Who was informed, by name and role, and when.
- Follow-up: when you will offer again and what you will monitor.
Capacity and consent
According to the CNO consent guideline, valid consent must relate to the proposed treatment, be informed and voluntary and not be obtained by misrepresentation. A person is capable if they understand the relevant information and can appreciate the reasonably possible consequences of their decision. Capacity is assessed for a particular decision, and rules differ by province, so follow your employer's process and regulator.
A fictional example
"20:30 Offered Mr. D. the scheduled evening oral medication ___. He said, 'I am not taking that tonight; it makes me sick.' Explained that the medication is for ___ and that skipping a dose may ___. He repeated back that he understood he could take it later. Asked if a different time would help; he agreed to try at 22:00. Alert, oriented, speaking clearly. Informed Nurse L. (charge nurse) at 20:40 and the prescriber was notified at 20:50 about the nausea. 22:00 offered again; medication taken with crackers. No further concerns."
The note shows the offer, the words, the information given, the alternative, the escalation and the outcome.
If you are a PAB or PSW
Report a refusal to the nurse, especially when it affects safety, such as refusing meals, fluids, help to move or toileting. Write what you offered, the words used and who you told. You do not explain medical consequences; the nurse does.
Forms
Some employers have a refusal form or require specific wording in certain situations. Use your workplace's forms and policies; this page does not replace them.
Common mistakes
- "Patient refused" with no detail of what and why.
- Labelling the person "non-compliant" instead of describing what happened.
- Leaving out who was told.
- Documenting refusal without checking whether the person understood.
- Not offering again or recording the follow-up plan.
Where Fiabita fits
Fiabita's rewrite tools can help restructure rough notes into clearer wording, and you review every line before it goes in a chart. Fiabita does not know your employer's policy, cannot certify that a note is compliant and does not replace clinical judgment.
FAQ
Q: Can a patient refuse any care?
A person with capacity can generally refuse care, but the rules, including for emergencies and for people who lack capacity, vary by province and situation. Follow your employer's policies and ask a senior colleague.
Q: Do I need a signed form?
Only if your employer's policy requires one. A clear note is still needed.
Q: What if the patient's family disagrees?
Report the situation to the responsible nurse or prescriber according to your policy and document what was said and who you informed.
Sources and further reading
- CNO Consent practice guideline (updated July 2025) — Ontario guidance on consent, capacity and refusal; check your own regulator
- CNO Documentation practice standard (revised September 2025) — Ontario standard, useful as a model elsewhere; check your own regulator