How should you document a decision when you override a client’s instruction in the interest of safety?

• A. Record the rationale, risk assessment, alternatives considered, and consent or notification to the client.
• B. Do not document to avoid blame.
• C. Document only the final decision without rationale.
• D. Notify the client verbally but not in writing.

Answer: (A)

When safety requires overriding a client’s instruction, the record should reflect a complete decision trail. Document why the override was necessary, including the specific risks identified, how severe and likely they were, and what alternatives were considered and why they were not chosen. Note what action was taken and whether the client was informed or gave consent, or at least notified about the decision. This creates a clear, auditable account of professional judgment and ensures continuity of care and accountability.

Why this is the best approach: it protects both the client and the practitioner by showing that safety concerns were thoughtfully evaluated and that appropriate steps were taken to inform the client and address risks. It also provides evidence in case questions later arise about the decision-making process.

Not documenting, or recording only the final outcome, undermines accountability and can lead to misunderstandings or disputes. Relying on verbal notification without a written record increases the risk of miscommunication and makes it harder to verify what was discussed or agreed.