Documentation of a refusal must include which of the following?

The documentation of a refusal must include the patient's decision-making capacity because it is essential to ensure that the patient is in a mental state to make informed choices about their own healthcare. This aspect establishes that the patient understands the nature of their condition, the proposed treatment, the potential risks associated with not receiving the treatment, and the consequences of their decision.

Assessing decision-making capacity also protects both the patient and the healthcare provider by documenting that the refusal was made with an understanding of the implications. This is particularly important in situations where the patient may be communicating a refusal despite a medical recommendation, as it confirms that they are capable of understanding their choices.

While the patient's identification, time of refusal, and witness signatures may be important components of a comprehensive refusal documentation process, the core focus remains on decision-making capacity, as it directly relates to the patient’s ability to make sound choices regarding their health.