Page 7 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

CASE STUDY

A 10-year-old male with congenital vascular malformation of
upper lip and mouth (AVM) underwent ethanol sclerosing

injections at the regional hospital to dry up the vessels. He

suffered circulation loss in the skin of his lip resulting in necrosis
and requiring reconstructive surgery. The exact nature of the

complication may not have been specifically explained to the
parents. The documentation reads “I discussed indications,

expectation and possible complications of the procedure with
the parents and they accept them.” There was no documentation

of any literature or printed material given to the parents about

this risk. The case was settled.

It is well established that patients have the legal right to sufficient

information with which to make an informed decision as to the

course of their medical treatment. Additionally, AMA Code of

Medical Ethics Opinion 2.1.1 sets forth the obligation of a physician
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to give a patient adequate information so that he or she may

exercise effectively a right of self-decision. Engage in a full and

clear discussion with patients about the nature of their medical

condition, the recommended treatment plan and the risks, benefits

and alternatives. Doing so not only discharges your legal and
ethical obligation to provide patients with sufficient information

with which to make an educated election about the course of their

medical care, but may also help create realistic expectations on

the patient’s part as to the outcome of treatment. Be careful not to

https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-2.pdf
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