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1. Reason: The patient has decided to refuse a treatment or procedure because  .

2. Capacity: The patient has normal mental status and adequate capacity to make medical decisions.

3. Risks: Risks of refusal have been explained including  permanent disability and death.

4. Benefits: Benefits have also been explained, including the ability to determine the best treatment.

5. Understanding: The patient was able to verbalize understand and state the risks and benefits

6. Witnesses: Nurse  and family  .

7. Questions: The patient had the opportunity to ask questions

8. Plan B: The patient was treated to the extent they allow and knows they may change their mind

from emresource.org

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