Informed Consent Is More Than Just a Form

posted by Veronica Brattstrom on Thursday, December 06, 2018

Informed Consent Is More Than Just a Form

Informed consent is more than asking the patient to sign a form. The foundation of a good informed consent process begins with a discussion between the provider and the patient. 

The discussion must include your diagnosis, nature/purpose of the proposed treatment, risks/benefits of the treatment, alternatives and their risks/benefits and the risks/benefits of not receiving the proposed treatment. 

Following your discussion, to avoid allegations that you misguided or misinformed your patient, consider documenting the following:

  • Mental status of the patient 
  • Patients’ ability to understand the information provided
  • The patients’ reasons for giving consent/moving forward with proposed treatment
  • All questions posed by patients and your answers (use quotation marks when possible to record the patient’s actual statements and/or questions)
  • Your evaluation of the patients’ level of understanding based on their questions and responses
  • Use of the teach-back method to confirm patient understanding

For more information about using an informed consent process in your practice, contact us.

Blog Author

Veronica Brattstrom

Senior Risk Management Consultant

Veronica has provided risk management consulting services to healthcare professionals for more th...

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