There are two goals to achieve when documenting informed consent. The more
important is using the process of documentation to ensure that the physician
and the patient have the same understanding of the care being rendered—its
risks, benefits, and alternatives. The secondary goal is to document this
understanding in such a way that a third person, such as a juror, can
determine both what the patient was told and whether the patient had some
reasonable understanding of the implications of what was told.
Most of the literature on informed consent focuses on the consent form.
Although it is true that an undocumented consent is legally difficult to defend,
informed consent is more than just getting a form signed. A proper informed
consent starts with a discussion between the treating physician and the
patient. In this discussion, the physician discusses the risks of proposed
treatment and its alternatives. Most important, these risks and alternatives
must be discussed in the context of the patient’s prognosis. For example, the
same risks of general anesthesia have profoundly different implications for a
patient having a tooth pulled compared with a patient with an ectopic
pregnancy. The consent form serves to document the discussion between the
physician and the patient. It cannot substitute for it.