Page 9 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 The probable outcome, particularly if it is difficult to predict,

and the patient’s expected post-procedure and treatment

course

 Potential modifications or extensions of the treatment or

procedure

 The possible benefits of having the procedure

 The most likely, and the most severe risks and side effects of

the procedure, treatment or medication, preceded by a

general inclusive statement, such as “including but not

limited to”

 Reasonable alternative methods of treatment or no treatment,

including the risks, benefits, and the prognosis associated

with each alternative or with no treatment

 Notification of experimental or investigational procedures

 Clear, easy-to-understand documented instructions help

protect the patient and the physician. Is there a particular risk

that merits a special warning? If so, include that in the

documentation as well.

It is important to note that documentation of the informed consent

discussion should occur contemporaneously with the discussion

and prior to the performance of the procedure or surgery that is
consented. The practice of documenting the consent process

within the patient’s dictated operative note after the procedure

(rather than contemporaneously with the discussion) could

increase exposure. Therefore, it is recommended that physicians

include this documentation in the office visit note prior to

admission. In cases where the patient may not be seen in the

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