(Excerpted from Medical Economics, 10/17/2008)
Getting consent from a patient means more than having a form signed. Getting consent means having a conversation with the patient. Aside from state-mandated content in such a conversation, you are required to tell the patient the purpose of the procedure, recommended medication or treatment, and the risks, benefits and alternatives. Following such a conversation, the patient either consents or refuses.
When it comes to testimony in a trial, informed consent really boils down to a credibility issue. The patient-plaintiff will say there was no consent conversation, the doctor will testify that there was one. In such instances, the court will look to the records for a determination of what really happened. If there is no documentation of a consent conversation, the records will support the patient’s story. If there is proper documentation with a consent form and progress note, the records will support the physician – and possibly cause a favorable verdict.
The progress note is perhaps even more important than the consent form. After notating that a consent conversation took place and consent form signed, the progress note might read something like this: "The material risks, benefits and alternatives were fully discussed with the patient. The patient asked questions and fully understood the conversation. The patient consented to treatment."
If done properly, the consent form, the nformational conversation and the progress note will help both the patient and the doctor
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