What do you say in the patient record when your injured worker will not follow recommendations or healthcare provider treatment plans?
  • Use the word “declined” which is less negative than “refused”
  • “Never” or “always” should be avoided and replaced with objective statements: “more than 15 times”; “3 x per week”; “only once”; “not taken”,etc.
  • State the “facts”:
    • “Mr. Jones has not used his crutches while walking”
    • “Mr. Jones is requesting a second opinion because of…”
  • Describe behavior:
    • “Mr. Jones was walking on his right foot with a short leg cast without use of his crutches”.
    • “Mr. Jones will not return to Dr. Smith due to his belief that MD is not …”
  • Use an exact quote:
    • “Mr. Jones was stating that he will not use his crutches because of …”
    • “Mr. Jones states that after having his surgery with Dr. Smith, he now has an orange-size lump in the surgical site.”
  • Include your actions and information that you provided.
  • Make sure you describe your plan of action to eliminate the concern/problem.

Author: Deborah Goza, MS, RN, COHNS, CCM
Editor: Lisa Perry