Risk Management

Tips

Patient Informed Consent
May 2000

The physician’s duty to obtain permission from a patient before touching their body has its roots in the moral principle that every person is absolutely entitled to determine what happens to their body. Indeed, today, all physicians are legally obligated to obtain the informed consent of their patients prior to treatment. As a risk management tool, the process of informed consent serves several functions in addition to fulfilling this legal mandate.

Healthcare in general is much more complex for patients today than it has been in the past. In an effort to get answers to their questions, many patients turn to sources other than their physician for healthcare information. For example, information is available via the Internet, drug companies are marketing directly to patients through advertisements, and organizations are targeting specific patient groups, i.e. AARP. You, the physician, can help patients obtain accurate information by personalizing treatment plans and utilizing the informed consent process.

Informed consent is simply an explanation to the patient of the treatment or Procedure you recommend, your reasons for recommending it, Alternatives to the treatment (including doing nothing) and likely Risks of the procedure. Finally, the most important thing a physician can do to truly obtain informed consent from the patient is to ask if they have Questions. If so, address those questions as thoroughly as necessary. An acronym used to remember the steps in the process is: PAR-Q. Here are three tips to keep in mind:

Document your informed consent discussion in the medical record every time it occurs.

Ask the patient to sign an informed consent form memorializing the informed consent discussion for the following: (1) all out-patient invasive procedures; (2) long-term steroid or narcotic use; (3) trigger point injections which may possibly result in pneumothorax; (4) any other treatment or procedure that has side effects which may result in serious bodily injury.

Be certain you have an office system in place when performing invasive procedures to ensure the correct procedure is done on the correct patient and on the correct side of the body.

 

REMEMBER: When legal informed consent occurs, the patient agrees to share decision making and risks of a particular treatment with their physician. This involves the patient in a partnership and is, therefore, an excellent risk management tool.

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