Page 9 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

Clear, easy-to-understand, documented instructions help

protect both 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 office prior to the informed consent

discussion, this should be documented prior to the procedure
in a separate progress note or in the history and physical

documentation of the medical record. Some electronic health
records may also include a pre-programmed default which

would document that the material was given to the patient, that
a full discussion of the potential risks, benefits, and alternatives

of the proposed medications or treatment took place and that
the patient gave full consent. These systems should also allow

for an electronic authentication process to be employed by the
patient.

Informed Refusal

As discussed above, a fundamental component of consent is
providing the patient with sufficient information to make an

informed decision about the risks, benefits, and alternatives
of the proposed treatment. Clearly, one of the alternatives

to treatment is to forgo treatment. Patients have autonomy

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