Canadian Health Information Management Association Practice Exam

If a patient is unable or unwilling to sign necessary documents, what should be done?

1. A family member should be asked to sign

2. Make a note in the file about the refusal or inability to sign

3. Document the reason the consent is not signed

4. The patient/client will sign it later

The correct answer is: Document the reason the consent is not signed

When a patient is unable or unwilling to sign necessary documents, it is crucial to document the reason why the consent is not signed. This is important for several reasons. First, thorough documentation provides a clear record of the patient's situation and preserves the continuity of care. It ensures that healthcare providers are informed about the patient's decision-making capacity and reasons for not consenting, which is essential for legal and ethical considerations. By documenting the specific reasons for the lack of consent, healthcare professionals can demonstrate due diligence in their efforts to obtain consent and safeguard the patient’s rights. This documentation can also be invaluable in situations where legal or clinical questions arise later, as it provides a detailed account of the circumstances. While involving a family member could seem like a helpful option, it may not always be appropriate unless there is clear consent from the patient or legal authority. Merely noting an inability to sign is less informative than documenting the reasons, and assuming the patient will sign later can lead to misunderstandings or gaps in care if the situation changes. Hence, thorough documentation of the reason is the most responsible and legally sound approach in this scenario.