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Documentation

Documenting consent to medical care for minors is a special case of the general problem of documenting proxy consent: the person who may consent to the care is not the person receiving the care. The physician must first document the relationship between the person giving consent and the patient and then document the risks and alternative treatments that the consenting person was informed of. If the patient is a mature minor, the physician should also discuss the treatment with the minor and document this discussion.

If there are disputes between the parents about the treatment or about who has the authority to consent, these disputes should be documented. It is important to document the rationale for deciding to accept the consent for treatment. The medical necessity of the treatment should be stressed. All contacts with child protective services should be documented. If the child is hospitalized, this information should be copied into the hospital medical record. Physicians who render necessary care to children are seldom sued for failure of consent. Proper documentation is important to reduce the chance that the physician will be sued as an ancillary party in child custody battles.


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