Page 25 - 2021 Risk Reduction Series - Communication Part One

SVMIC Risk Reduction Series: Communication

Since lack of informed consent is often an allegation in a

malpractice lawsuit, a look at the specific documentation
requirements of informed consent is justified. Frequently in

claims where there is a bad outcome, we find the consent
process lacking, or at least the documentation of the process

less than optimal. Plaintiff attorneys are eager to assert the
adage that, “if not documented, it didn’t happen”. While this

is not necessarily true, a lack of documentation undoubtedly
complicates a physician’s legal defense.

To ensure the patient has been given adequate information from

which to make an informed decision as to the course of his/
her medical treatment, the following should be discussed and

documented in the medical record:

• Details of the nature of the patient’s illness and diagnosis

• Indications and benefits for the proposed treatment plan,

procedure, or medication, as well as the anticipated

prognosis

• A description of the proposed treatment or procedure,

including medication that will be prescribed and its
purpose

• The probable outcome, particularly if it is difficult to
predict, and the patient’s expected post-procedure/

treatment course

• Potential modifications or extensions of the treatment or

procedure

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