Recording a Refused Treatment or DNA: What to Write

Some of the most important notes are about things that did not happen: the treatment a patient declined, or the appointment they missed. These entries are easy to skip, precisely because nothing was done, and that is exactly why they matter. If a problem develops later, these are the notes that show the right advice was given and the decision rested with an informed patient.

This is general documentation guidance, not legal advice or a substitute for advice from your indemnity provider.

When a patient declines treatment

Record that treatment was recommended, why it was recommended, what you explained about the consequences of not proceeding, and that the patient understood and chose not to go ahead. The key is showing the patient made an informed decision, not just that they said no. A note that reads "patient declined" tells nobody whether the patient understood what they were declining. A note that records the recommendation, the explained consequences, and the informed refusal protects everyone.

It is also worth recording any plan that follows from the refusal: whether you will review, whether you advised them to return if symptoms change, and any safety-netting advice you gave.

When a patient does not attend

Note the missed appointment, what it was for, and any follow-up. For routine recalls a simple record may be enough. For clinically important treatment, record the steps you took: a reminder, a further appointment offered, or a letter where appropriate. A pattern of missed appointments for significant treatment is worth flagging clearly in the record, because it becomes relevant if the underlying problem later worsens.

Why these notes protect you

If a problem develops, these entries show that the right advice was given and that the patient, fully informed, made their own choice or failed to attend despite your efforts. Without them, the record can look as though nothing was offered or no follow-up was attempted, which is a far weaker position. The absence of a note about a refusal can be as damaging as a poorly documented treatment.

Keep it factual

Record what was said and done without editorialising or expressing frustration. A calm, factual entry is the most useful kind and reads well if the record is ever reviewed. Note the clinical facts, the advice, the patient's decision or non-attendance, and the plan.

A worked example

A patient is advised they need a particular treatment, declines it on cost grounds, and is told what could happen if it is left. The weak record reads "declined treatment." The strong record notes the treatment recommended, the reason, the specific consequences explained if untreated, that the patient understood and declined, the safety-netting advice to return if symptoms develop, and the plan to review. If the untreated problem worsens and the patient later asks why they were not warned, the strong note answers clearly and the weak note leaves the clinician exposed.

Frequently asked questions

Do I really need to document a patient declining treatment?

Yes. A refused treatment is one of the most important things to record, because it shows the advice given and the informed decision made.

What should a DNA note include?

The missed appointment, its purpose, and any follow-up, with extra care where the treatment was clinically important.

Should I record safety-netting advice?

Yes. Noting what you told the patient to do if symptoms change strengthens the record and supports good care.

How should I word these entries?

Factually and without editorialising: the recommendation, the advice, the patient's decision or non-attendance, and the plan.