Page 10 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

office prior to the informed consent discussion, this should be

documented prior to the procedure in a separate progress note or

in the history and physical documentation of the medical record.
Some electronic health records may also include a pre-

programmed default which would document that the material was

given to the patient, that a full discussion of the potential risks,

benefits and alternatives of the proposed medications or treatment

took place and that the patient gave full consent. These systems

should also allow for an electronic authentication process to be
employed by the patient.

Informed Refusal

As discussed above, a fundamental component of consent is

providing the patient with sufficient information to make an

informed decision about the risks, benefits and alternatives of the

proposed treatment. Clearly, one of the alternatives to treatment is
to forgo treatment. Patients have autonomy with regard to

healthcare and many patients elect to refuse treatment based on a

number of factors such as cost, health literacy, fear of a particular

procedure and cultural or religious considerations. When this is

the case, it’s important to document the patient’s reasons for
refusal as well as the physician’s discussion of the indications for

the treatment, consequences of refusal and any follow-up

conversations and educational materials provided to the patient.

Documenting a patient’s refusal to undergo a test or imaging study

is also important. Does a patient’s concern over cost cause the
patient to refuse certain tests or make a patient reluctant to obtain

follow-up appointments? If so, consider getting the patient to

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