Page 44 - APP Collaboration - Assessing the Risk (Part One)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

• The most likely and severe risks and side effects of the

procedure and treatment or medication, preceded by a
general inclusive statement, such as “including but not

limited to”

• Reasonable alternative methods of treatment or no
treatment, including the risks, benefits, and the prognosis
associated with each alternative or with no treatment

Documenting the Process

It is imperative that all of the steps be appropriately documented

by the provider who will render the care. The most thorough
informed consent process may be negated if there is no

contemporaneous documentation to evidence that such a
process took place. Plaintiff attorneys are eager to assert the

adage that “if it wasn’t documented, it wasn’t done”. While this
is not necessarily true, the lack of documentation may unduly

handicap the physician’s legal defense.

Poor or absent documentation forces a physician to testify

from memory about an event which probably occurred several
years earlier and negatively impacts his/her credibility as a

result. Furthermore, poor or absent documentation may be a
significant factor in a patient’s attorney’s decision to pursue legal

action in the first place. On the flip side, a well-documented and
thorough informed consent process may convince a plaintiff’s

attorney to abandon previously considered litigation. The benefit
of a signed form is that it gives rise to a presumption of consent

in the absence of proof of misrepresentation, inadequate
disclosure, forgery, or lack of capacity.

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