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Minimize liability when it comes to informed consent

HIM Connection, July 10, 2003

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TOPIC: Minimize liability when it comes to informed consent

Informed consent for a procedure or anesthesia is a process between the physician and the patient, according to current legal opinions. Physicians have the responsibility to document that they discussed their assessment and recommendations with the patient, including the risks and benefits of the recommended course of treatment and other treatment options.

If this discussion occurs between the physician and the patient (and sometimes the patient's family), it stands to reason that the physician should document this activity in the medical record. All too often, physicians count on a hospital's or other facility's staff to obtain a patient signature on an informed consent form as adequate documentation.

Best practices today involve the physician sitting down with the patient, including his or her family if appropriate, and dedicating adequate time and attention to the process of obtaining informed consent.

Immediately after, the physician should document in the medical record that the activity occurred, and include a brief summary of the content that was discussed. The physician's medical record entry is the most important element of documenting adequate informed consent. Obtaining a patient's signature is secondary, but it does provide a degree of added protection. Some physicians ask the patient to sign their chart entry describing the informed consent.

The toughest protection can be provided by a chart entry that includes a diagram of the anatomy and the planned procedure accompanied by a description of the risks, benefits, and alternatives discussed, as well as a statement by the physician describing the process of obtaining informed consent with this entire chart entry cosigned by the patient.

The most common practice-that of having a member of the facility's staff obtain a patient's signature on an informed consent form-provides the least protection, since the person obtaining the signature usually did not participate in the process of obtaining informed consent.

This week's HIM Connection was adapted from an excerpt of the handbook, "Documentation Improvement Handbook for the Medical Staff." Written in a convenient question-and-answer format and sold in a package of 25 handbooks for $99, it covers everything physicians need to know to improve documentation, covering subjects such as timeliness, legibility, and informed consent. Sincerely, Laura Motta Editorial Assistant lmotta@hcpro.com

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