Informed consent is more than asking the patient to sign a form. The foundation of a good informed consent process begins with a discussion between the provider and the patient.
Posted in Risk Management on Monday, March 28, 2022
The discussion must include your diagnosis, nature/purpose of the proposed treatment, risks/benefits of the treatment, alternatives and their risks/benefits and the risks/benefits of not receiving the proposed treatment.
Following your discussion, to avoid allegations that you misguided or misinformed your patient, consider documenting the following:
- Mental status of the patient
- Patient's ability to understand the information provided
- The patient's reasons for giving consent/moving forward with proposed treatment
- Facts related to the patient's health history
- Answer all questions posed by patients
- When possible, use quotation marks to record the patient’s actual statements and/or questions
- Education discussed and provided
- Discussion of expectations and limitations the patient may experience following the procedure
- Date/time the consent was obtained
- Witnesses present for the informed consent process
- Use of interpreters, if applicable
- Your evaluation of the patients’ level of understanding based on their questions and responses
- Use of the teach-back method to confirm patient understanding
Patients may not remember whether the physician explained the procedure and/or potential complications. Avoid the "he said, she said" scenario by following a good informed consent process.
For more information about using an informed consent process in your practice, contact us.