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