The informed consent discussion gives a doctor the unique opportunity to build rapport and trust with patients. It is a thorough discussion that enables the doctor to educate the patient on the recommended treatment.
by Keith Henaman in Documentation on Wednesday, February 6, 2019
Informed consent is a topic that’s often talked about. It is through this discussion that doctors are able to educate patients about recommended treatments.
Doctors may be accused of negligence or battery if they fail to obtain the patient's proper informed consent before rendering treatment, and they may be sued for not providing information regarding potential complications.
Components of informed consent include a discussion about the risks, benefits and alternatives of the proposed treatment. After the discussion, the doctor should have the patient sign a document that confirms the discussion and that the patient was given the chance to ask questions and have them answered.
An effective informed consent process should include these steps:
- Provide the patient with sufficient time and information to make decisions about the risks, benefits and anticipated outcomes of the proposed treatment.
- Present the patient with alternatives, including referral options or receiving no treatment at all. If you make a recommendation, explain your reasoning and why you believe it is a valid suggestion.
- Discuss any foreseeable risks or complications that may arise from the proposed course of care, as well as the potential risks if the patient refuses care.
Make sure to document both the discussion and the patient's decision, including a written informed consent (or refusal) to support the verbal response. You should note the following in your records (and provide the patient with a copy):
- Names of individuals present (patient, family, caregiver) during the discussion.
- The treatment recommended.
- Potential risks that were discussed of not following the treatment.
- Any questions the patient or related parties asked and the answers you provided.
In the case of refusal, also note:
- The patient’s reason for refusal of the recommended care.
If the patient returns for further treatment, continue to:
- Advise the patient about the condition and risks, as long as the condition exists and the patient refuses treatment.
- Advise the patient if other conditions may be affected by their continued refusal of the recommended treatment.
- Document that the patient continued to refuse the recommended treatment.
See the article about providing informed consent for related information.