Documenting Consent
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.