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Informed Consent Is 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 
  • Patients’ ability to understand the information provided
  • The patients’ reasons for giving consent/moving forward with proposed treatment
  • All questions posed by patients and your answers (use quotation marks when possible to record the patient’s actual statements and/or questions)
  • Your evaluation of the patients’ level of understanding based on their questions and responses
  • Use of the teach-back method to confirm patient understanding

For more information about using an informed consent process in your practice, contact us.

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