# Refusal of Treatment



## laurenb (Nov 15, 2013)

If a patient refuses the treatment the Doctor is requesting, do you still give the Doctor credit for ordering it?

Example Dr. wants to send patient for ultrasound and lab work and the patient refuses, stating "do not bother, I am not going for it." 

Thank you


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## Pam Brooks (Nov 15, 2013)

As long as the order is written, I'd give credit for the intent. The intent was there to obtain further information.  Certainly in any other instance when the order is written for lab/rad/medicine diagnostics, the fact that whether or not the patient leaves the office and actually has the test done, is not the requirement of the calculation of MDM.  Patient non-compliance can actuall increase the risk of care, but I wouldn't necessarily count it at this visit.


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## MnTwins29 (Nov 15, 2013)

Agree with Pam.  The physician ordered the test, so he or she should get the data points regardless of whether or not the patient followed through.  Often that won't be known when reading the progress note for only that date of service.   Same goes for the table of risk for the particular test.


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## laurenb (Nov 22, 2013)

Thank you both, that is what I was thinking.


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