What is Informed Consent?

Informed consent is the process in which a patient gives permission to have a treatment performed. Obtaining consent should include a discussion of treatment Risks, Benefits, Alternatives and an agreement form when applicable.

Understanding Elements of Informed Consent

1. Documentation 
   • Document the entire process and conversation
   • Explain any educational tools or visual aids used
   • Mention any documentation that was signed
   • Include post operative instructions or handouts
2. Patient Education – A consenting patient should understand the following items:
   • Diagnosis – Include the actual diagnosis and layman’s terms used
   • Treatment Options – Your recommendation should be included
   • Treatment Risks – Consider likely and unlikely treatment outcomes, risk of no treatment, and non compliance to pertinent instructions
   • Treatment Alternatives – This should include no treatment
3. Effective Communication – This is a crucial element to informed consent. Understand the patient’s Chief Complaint. Ensure your patient feels comfortable enough to ask questions and have opportunities to ask. Take time to ensure that you understand how your patient feels about your recommended treatment, their options, and what their expectations are.
4. Signed Documentation – When appropriate, use forms to obtain written consent.
5. Authority to Consent – Understand individual state laws regarding who can authorize treatment and ensure that any language barriers are considered.  

As we discussed in 10 Tips On Writing Excellent Treatment Notes, please understand that if a treatment element was not recorded in your treatment notes, it could be argued in a legal setting that it did not occur.