Refusal of Care / Treatment Nursing Note Example
A refusal note documents that a patient declined an offered care item, what they said, what information was provided, and who was informed.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
A refusal entry should be neutral and factual. Quoting the patient's reason, and noting what was explained, supports the team's follow-up and respects the patient's choice without judgment.
When this may be used
- When a patient declines care, medication or treatment.
- Specific refusal procedures and forms vary by organization and are not legal advice.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Components
What was offered
Care declined.
What belongs here
- The specific care or medication
What does not belong
- Vague "refused care"
Patient's reason
In their words.
What belongs here
- Direct quotes
What does not belong
- Judgments such as "noncompliant"
Information given
Explanation.
What belongs here
- What was explained
What does not belong
- Pressure or threats
Notification and follow-up
Communication.
What belongs here
- Who was informed; plan to re-offer per policy
What does not belong
- Notifications not made
Short fictional example
- Narrative
- 1000: Offered assisted walk in hallway. Patient declined, stating "I'm too tired right now, maybe after lunch." Will offer again after lunch.
More detailed fictional example
- Narrative
- 2100: Scheduled subcutaneous enoxaparin offered. Patient declined, stating "I hate shots, I'm bruised all over." Explained the purpose of the medication as listed in the order. Patient continued to decline. 2110: Provider notified by phone of refusal. No new orders. Refusal documented in the MAR per policy.
Annotated example
Notes on the detailed example above:
stating "I hate shots, I'm bruised all over."
— The patient's reason in their words, without judgment.Explained the purpose of the medication
— Documents the information given.
Common mistakes
- Labeling the patient "noncompliant" or "difficult."
- Leaving out what was explained.
- Not documenting who was informed.
Good vs poor documentation
Weaker (fictional)
Patient uncooperative, refused shot.
Stronger (fictional)
Patient declined enoxaparin, stating "I hate shots, I'm bruised all over." Purpose explained; patient continued to decline.
Why: Neutral, factual and quoted.
Blank educational template
Narrative note: A chronological account in full sentences. Prompts only; nothing is prefilled.
- Time / context
- [Time of entry and reason for the note]
- What was observed or reported
- [Assessment findings actually obtained; patient statements in quotation marks]
- What was done
- [Nursing actions actually performed, and by whom if not you]
- Response and follow-up
- [Patient response, reassessment and any notification actually made]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- Good vs poor documentation
- Provider notification
- Medication response
- NCLEX Psychosocial Integrity review — Therapeutic communication.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.