Page 44 - Hospitalists - Risks When You're the Doctor in the House (Part One)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

Nearly all hospitals use an electronic health record (EHR)

these days, but regardless of the system used, the informed
consent process should be documented through a procedure-

or medication-specific consent form or through a detailed note
in the medical record. Both forms of documentation should

reflect all pertinent information given to the patient, specify any
supplemental information given, and indicate that the patient

was given the opportunity to ask questions and receive answers.
The name of any witness to the consent process should also

be recorded on the consent form or in the medical record, and
written documentation should be made as soon as possible after

verbal consent is given. It is a good idea to have a place on the
consent form for the patient to sign, preceded by a statement

that he or she understands the information given and consents
to the medical intervention. Documentation of the consent

process in the medical record should be dated and signed by
the practitioner. In an electronic system, this may require that

the forms be printed and then scanned after signing, or that the
system allows for an electronic authentication process to be

employed by the patient.

Avoid the use of summary statements such as, “The patient was
advised of the potential risks/complications of the operation

and alternatives.” Rather than using this boilerplate and generic
language, note at least some of the actual risks, complications,

and alternatives discussed with the patient. For example, a
better entry would state that “information regarding the risks,

complications, and alternatives was discussed with the patient
and/or family, including but not limited to…”, followed by the

specific information discussed and any questions asked by the
patient.

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