Page 7 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

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
1
a physician 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 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 non-delegable 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 or administering treatment.

Documentation issues are a factor in the majority of claims paid
in general surgery. Often, medical record notes simply reflect

“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

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