Page 8 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

educate above a patient’s comprehension level. Be sure the details

of all discussions with patients are documented in your office

record rather than relying on hospital consent forms that are not
procedure specific and may not capture all details of the

conversation. Remember, obtaining informed consent is a

nondelegable duty. The responsibility for ensuring that an

informed consent form is properly completed and signed by the

patient rests with the physician performing the procedure.

During 2010-2015, documentation issues were a factor in 52% of

claims paid in general surgery. Often, medical record notes simply

reflected “risks and benefits discussed” without any documentation

of the procedure-specific risks and benefits, and no further

indication that alternatives and expected outcomes were likewise
discussed. When a known complication occurred, the failure of

the record to reflect that the procedure-specific risks, benefits and

alternatives were thoroughly reviewed opened the door for the

plaintiffs to contend that they had indeed not received such

information, and further, if they had, they would have sought more
conservative treatment or a second opinion.

In order to ensure that the patient has been given sufficient

information with which to make an informed decision as to the

course of his or her medical treatment, the following should

generally be discussed and documented in the medical record:

 Indications for the proposed treatment plan, procedure or

medication, as well as the prognosis

 A description of the proposed treatment or procedure,

including medication that will be prescribed, and its purpose

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