Page 27 - OB Risks - Delivering the Goods (Part One)

SVMIC Obstetrics Risks: Delivering the Goods

delivery. All these discussions need to be documented. SVMIC

is here to help you with sample forms on informed consent,
informed refusal, and procedures including:

• Cesarean delivery

• Induction of labor

• Vaginal delivery

• Trial of Labor After Cesarean (TOLAC)

Find additional resources and samples of consent forms to use
for obstetrical deliveries at vantage.svmic.com.

The practice of documenting the consent process in a note
after the procedure or medication is given could be viewed as

self-serving if there is an unanticipated event. Accordingly, it
is recommended that physicians include this documentation

prior to the commencement of the procedure or medication
in a separate progress note or in the history and physical

documentation of the medical record.

Nearly all hospitals use an electronic health record these
days, but regardless of the system used, the informed consent

process should be documented thoroughly and extensively in
the medical record.

Elements to Include

All documentation should reflect all pertinent information given
to the patient, specify any supplemental information given,
and indicate that the patient was given the opportunity to ask

questions and receive answers. The name of any witness to the

consent process should also be recorded on the consent form
or in the medical record, and written documentation should be

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