Medication Refusal Record

What should you record after a medication refusal?

Everyone has the right to decline a medicine, and care workers must never force a person to take one. What they must do is write down what happened and tell the office. This medication refusal record gives home care workers one form for each medicine declined at each visit, so the manager can see the reason, the advice given and any pattern over time.

What the form asks

• The person, the medicine, its dose and route, and the time it was due

• The type of support agreed in the care plan: reminding, helping the person take it, or giving it

• Whether it is time-sensitive, meaning a late or missed dose may cause serious harm, as with insulin

• What the person said or did, in their own words, and whether they seemed in pain, unwell or upset

• What happened when the medicine was offered again, and what happened to the declined dose

• Any concern about capacity, health changes, stockpiling or someone else taking the medicine

• Who was told, and a manager review at the end

At the visit

1. Wait a short while, then offer the medicine again.

2. Ask about reasons such as pain or discomfort.

3. Record code R on the MAR chart.

4. Fill in this form during the visit or straight after it.

5. Tell the office before you leave, and the office asks the prescriber or a pharmacist for advice when needed.

Never disguise a medicine unless the care plan authorises covert administration after the Mental Capacity Act process. The form also reminds staff to assume a person has capacity unless it is shown they lack it. An unwise decision is not proof of that.

Manager review and setting it up

The manager counts how often the medicine was declined over a period you choose. They note any pattern, actions agreed with the prescriber, a care plan review, whether a mental capacity assessment is needed for this decision, and whether a safeguarding concern was considered.

Before you use it, add your office and on-call numbers. Agree with your local prescribers and pharmacies how staff can get advice quickly, above all for time-sensitive medicines.

The form links to three other home care records. Code R goes on the Medication Administration Record (MAR Chart), the visit itself goes in the Daily Care Notes / Visit Record, and your Medicines Management Policy & Procedure sets out the full refusal steps.