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Informed Consent Explained

What is Informed Consent?

Almost every visit to the doctor requires a little paperwork. And, while most people see this as busy work, all forms are important for a patient�s own privacy and health. One such form of patient security is informed consent. Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient�s authorization or agreement to undergo a specific medical intervention. It is a process in which a fully informed patient can participate in choices about their own health care. Informed consent originated from the legal and ethical right the patient has in choosing what happens to their body and from the ethical duty of the physician to involve the patient in their health care decisions.

Why is Informed Consent Required?

Informed consent is a physician�s non-delegable duty. The most important goal of informed consent is to provide a patient the opportunity to be an informed participant in their own health care decisions. The following are generally accepted situations in which complete informed consent is included in the discussion:

  • The patient�s diagnosis, if known
  • The nature and purpose of a proposed treatment or procedure
  • The relevant risks and benefits of a proposed treatment or procedure
  • Alternatives (regardless of cost or extent to which the treatments options are covered)
  • The risks and benefits of the alternative treatment or procedure
  • The risks and benefits of not receiving or undergoing a treatment or procedure
  • Assessment of the patient�s understanding
  • The acceptance of the intervention by the patient

    How Does Informed Consent Protect Physicians?

    Informed consent helps protect physicians if the standard of care is questioned or if an incident occurs while a patient is under their care. To protect yourself in litigation, it is important that the communication process itself be documented. Accurate documentation can serve as evidence in a court of law that the process indeed took place. Timely and thorough documentation in the patient�s chart by the physician providing the treatment and/or performing the procedure can be a strong piece of evidence that the physician engaged with the patient in an appropriate discussion.

    When is Documentation Recommended?

    Signed informed consent forms are the culmination of critical dialogue required to foster the patient�s informed participation in the clinical decision. For a wide range of decisions, a meaningful discussion is always needed, but written consent may not be required or necessary. For hospital-based procedures, documentation of the communication process is recommended in the admitting History and Physical or the first Progress Note. Documentation of the Operative Report is discouraged, as it may be misleading as to when the discussion took place or if the patient was in a state of mind to make an informed decision. For outpatient surgery procedures, you may not write progress notes, so it may be appropriate to include the documentation of a discussion with the patient in the Operative Report. In these circumstances, it is suggested that this be documented under a separate heading of �indications/discussions�, rather than �Procedure in Detail�.

    Informed consent is a process of communication between a patient and physician that results in the patient�s authorization of a medical intervention, and also protects physicians in malpractice claims or suits. Informed consent is a necessary component of any medical practice, as well as an innovative, flexible, and experienced medical liability insurance policy. If your practice is in need of quality, medical professional liability coverage, invest in your future with a medical professional liability insurance policy with API Risk Management Institute.

    Submitted by:

    Ethan Luke

    Medical liability insurance - API Risk Management Institute provides high quality medical professional liability insurance to physicians and other medical professionals in Texas, Arkansas and Oklahoma.


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