Question

Does the offer to counsel need to be documented? Does the refusal of the offer need to be documented? How?

a) Both the offer and refusal should be documented in the patient's file
b) The offer should be documented, but the refusal is not necessary
c) Neither the offer nor the refusal needs to be documented
d) The offer should be documented with a signed form, but the refusal is not required to be documented

Answer 1

Both the offer to counsel and the refusal should be documented in the patient's file.

Step-by-step explanation:

The offer to counsel and the refusal of the offer should be documented in the patient's file. It is important to have a record of the offer to provide evidence that the patient was given the opportunity to receive counseling. Documenting the refusal is also important as it indicates that the patient made an informed decision to not seek counseling.