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Record Keeping and Consent

Obstetric care demands special diligence in record keeping. Most of the lawsuits involving genetic counseling and fertility-related problems stem from claims concerning improper information rather that technical failures in medical procedures. The structured maternity record should incorporate entities for all of the relevant postconception recommendations for screening tests and the evaluation of their outcomes. There should also be a structured precounseling record to ensure that a proper genetic history is obtained from every woman and that she in turn receives complete information about potential problems and screening tests.

Genetic counseling should be done before conception. This is impossible for women who first seek medical care after conception but is simple for women who specifically seek preconception care. Physicians providing primary care for women with childbearing potential should discuss the importance of preconception counseling when they discuss contraception with their patients. Physicians should also consider obtaining a basic genetic disease history as part of the initial history when the woman begins her care. If this initial history demonstrates any risk factors, these can be discussed at the first patient visit. Bringing up a genetic disease history at the first visit also gives patients an opportunity to obtain information about their families' genetic history, if warranted.

It is critical to document the information given to the patient about her own specific risk factors: advanced maternal age, a history of genetic illness in her family, or an ancestor in a high-risk group for genetic illness. The physician must ensure that these risks are not lost in the boilerplate information that is provided to every patient. Patient information sheets on specific, identified risks should be differentiated from general information sheets. For example, they could have a place at the top to write in the patient's name and note that she has a special risk for the condition.

As with other medically indicated testing, it is as important to document the patient's informed refusal as to document the patient's informed consent to the test. Unless the test is hazardous, it is much more likely that a poorly documented refusal will result in litigation than will an equally poorly documented consent. The physician should periodically review the original recommendation with the patient to reinforce the importance of the test and to allow the woman to reevaluate her decision. It is not unusual for a woman's attitude toward testing for congenital disease to change as her personal situation and attitude toward pregnancy change with time.

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