Page 26 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

Documenting the Process

What are best practices when documenting consent?

Informed consent should always be a conversation that is
documented in the medical record and not merely a preprinted

form. It is imperative that all the steps be appropriately
documented by the physician or other provider who renders

care. The most thorough informed consent process may
be negated if there is no contemporaneous documentation

to evidence that such a process took place. Poor or absent
documentation forces a physician to testify from memory about

an event which probably occurred several years earlier and
negatively impacts his/her credibility as a result. Furthermore,

poor or absent documentation may be a significant factor in
a patient’s attorney’s decision to pursue legal action in the

first place. On the flip side, a well-documented and thorough
informed consent may convince a plaintiff’s attorney to abandon

previously considered litigation.

Documentation of the informed consent process should
occur contemporaneously with the discussion and prior to the

performance of a procedure. For example, in the obstetrics
setting, the documentation of informed consent related to the

delivery type should likely occur in the third trimester in the
prenatal office visit setting. Many practices have a specific

scheduled visit to have the consent discussion and sign the
necessary forms, typically in the timeframe of 35-36 weeks, or

when the GBS culture is obtained. If the patient is considering
a VBAC, a detailed discussion that includes the risks and

alternatives is conducted during the first pre-natal visit and at
35-36 weeks as well as when the patient arrives at labor and

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