Page 24 - 2021 Risk Reduction Series - Communication Part One

SVMIC Risk Reduction Series: Communication

Risk Management Tip:

Be sure the details of all discussions

with patients are documented in the
medical record. Relying solely on

hospital consent forms that are not
procedure-specific may not capture

all details of the conversation.

While this course is directed at communication and not
documentation (to learn more on documentation, refer to

the SVMIC course Risk Reduction Series: Documentation

Essentials), we would be remiss if we did not stress the
importance of proper documentation of physician-patient
communication. Most often in the cases we reviewed, the only

documentation associated with the consent process was a

boilerplate hospital consent form which unfortunately failed to
reflect the details of the discussion between the physician and
patient. Without an accurate and detailed informed consent

note, a physician’s ability to argue that a complication was

adequately explained and understood by the patient prior to the
procedure may be crippled, and indeed, may prove fatal to the
defense. Remember, the discussion that takes place between

the physician and the patient (or patient’s legal representative)

is what constitutes the basis for the consent to be informed. The
consent form that is signed by the patient or representative is
merely evidence memorializing that the discussion took place

and the patient or representative understood the information

discussed.

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