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Control Number: <br />401.06.03.071 <br />Version: <br />2.1 <br />Title: <br />Right to Refuse Treatment <br />Page Number: <br />4 of 6 <br /> <br />2. Process Steps <br />Note: The contract medical provider is responsible for supplying and providing any <br />forms or lists indicated in this section. <br /> <br />Functional Roles and <br />Responsibilities Step Tasks <br />Qualified Healthcare <br />Professional 1 <br />• Provide information sufficient enough for an offender <br />to make an informed decision to refuse <br />recommended healthcare evaluations and/or <br />treatment. <br />• If the offender requests, a more detailed explanation <br />must be provided to include details of the <br />recommended evaluation and/or treatment, the <br />viable alternatives, and any material risks to the <br />recommended evaluation and/or treatment. <br />Note: Treatment is mandatory for an offender who has <br />latent tuberculosis infection (LTBI) and/or active <br />tuberculosis (TB) (see SOP 401.06.03.076, Tuberculosis) <br />or when he does not have the mental capacity to make an <br />informed decision (see SOP 401.06.03.070, Informed <br />Consent). <br /> <br />Note: If an offender does not speak English, a written <br />interpretation or telephone interpretation service must be <br />provided in the language spoken. <br />Qualified Healthcare <br />Professional 2 <br />If the offender refuses evaluation and/or treatment: <br />• Complete the Treatment Refusal Form, <br />• Secure a healthcare staff member to serve as a <br />witness, <br />• Have the offender sign and date the form in the <br />presence of the witness, and <br />• Have the witness sign and date the form in the <br />presence of the offender. <br />Note: If the offender refuses to sign the form, have the <br />witness sign and date the form indicating the offender’s <br />refusal to sign. <br />If the offender accepts evaluation and/or treatment: <br />• Take steps to obtain informed consent (see SOP <br />401.06.03.070, Informed Consent) and provide the <br />evaluation and/or treatment. (The process ends <br />here.) <br />Qualified Healthcare <br />Profession 3 <br />• Document the information provided, circumstances, <br />and the offender’s stated reason for refusal in the <br />“progress notes” section of the healthcare record, <br />and <br />• Forward the healthcare record to the facility medical <br />director (or designee) for review.