Why you should never document patient refused treatment.

Why you should never document patient refused treatment. Instead you should document: Patient verbalized understanding of risks/benefits of treatment and declined. Provider notified; education re-offered. Patient stated, "I don't want insulin." Explained risk of hyperglycemia; re-checked glucose in 1 hour. Will continue to monitor BP q15 min per protocol; report any change > 20 mmHg to MD. Sometimes in the hospital you get super super busy and then you forget to document things, but that can cost you your license. And this book here gives specific example as to what you should be documenting. Don't document subjectively like "patient acting weird." Instead, document objectively, what you see. Patient pacing room, speaking rapidly, stating "I can't calm down." This book gives specific examples and it helps you realize that how important your charting actually is when you have to go to court. If you want to improve your documentation and protect your license, I'm going to try to drop the link to this book down below. But this book has been going viral and they have been selling out pretty fast, so if you do see the link available, that means they are still in stock.