At times, patients may refuse treatment. It is the duty of the doctor to first fully explain to the patient or his/her attendants about the risks and the possible adverse outcomes, if they refuse the recommended treatment or the diagnostic procedure. This is called informed refusal and it is essential to document the informed refusal.

Documentation should include the need for intervention, as well as risks, benefits and alternatives to the intervention, and that the possible consequences of refusal have all been explained to the patient. It is also important to document the reason why the patient refused to undergo the treatment.

Documenting informed refusal is as important as informed consent.