What step should be taken if a patient refuses medication?

When a patient refuses medication, it is essential to document the incident and proceed with care. This step is crucial because documentation serves as a record of the patient's choice and the healthcare provider's response. It ensures that there is a clear account of the refusal, which could be important for legal and medical reasons. Additionally, by documenting the refusal, you provide a basis for any necessary follow-up or adjustments to the patient's care plan. This practice also respects the patient's autonomy in making decisions about their own treatment.

Proceeding with care is vital because it does not mean you ignore the refusal; instead, you continue to assess the patient's needs and comfort while being responsive to their choices. It is important to maintain a therapeutic relationship, facilitating further discussions about the medication, its purpose, and addressing any concerns the patient may have.

While monitoring the patient closely and reporting the refusal are components of responsible care, the primary immediate action should indeed focus on documenting the refusal as well as continuing to engage with the patient. Administering the medication at a later time without reporting would disregard the patient’s right to refuse treatment and could undermine the trust in the patient-provider relationship.