Dear RN,
When your patient refuses medication
This is an example of how you document
“Declines IV antibiotics and renal ultrasound.
Educated on the importance of antibiotics and diagnostic imaging for proper care and evaluation.
Verbalizes understanding of risks and benefits, but continues to decline. Alert and oriented x4, speaking clearly.
Made aware he can reconsider at any time. Vital signs are stable, see flowsheet.
Pt’s provider made aware of patients refusal.”
Cheers 🥂