How should refusals of medical treatment be documented after a force incident?

• A. Do not record the refusal to protect privacy
• B. Record the refusal, explain consequences, and include it in the incident report
• C. Document the refusal only in a separate medical file
• D. Treat the refusal as if it did not occur

Answer: (B)

When someone in a force incident refuses medical treatment, the important practice is to document that refusal clearly, along with the consequences explained, and to include it in the incident report. This creates a complete, auditable record of what was offered, what was understood, and the risks the person chose to accept by declining care. It protects the patient’s autonomy while also safeguarding staff and the agency by showing that medical options were presented and the potential outcomes were explained. Keeping the refusal as part of the incident report ensures that anyone reviewing the case—medical personnel, supervisors, or legal entities—has a full picture of the decision and the reasons behind it, which is essential for ongoing care and accountability.

Not recording the refusal or treating it as if it didn’t happen ignores the patient’s right to refuse and creates safety and liability gaps. Placing the refusal only in a separate medical file can lead to fragmentation, making it harder for those involved in the incident to access the information when needed.