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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.