Doctor discusses an informed consent from with a patient.

Informed Consent: More Than Just a Form

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.

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.