Informed Consent


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Subject: Informed Consent

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The principle of self-determination is the cornerstone of the American legal system. Rooted within this principle is the doctrine of informed consent, which posits that a competent individual or the individual’s representative has the right to receive adequate information to form an intelligent decision regarding a proposed procedure. Although the information included in informed consent varies from state to state, the key component that must be included is information that a reasonable patient would need to know about the risks of a proposed procedure that might cause the patient not to undergo that treatment. 
There are several key issues: 
  • The medical record is considered faithful documentation of what information was transmitted to the patient; the medical professional must provide complete notes.

  • Courts assume that “if it’s not written, it didn’t happen.”

  • The physician’s word that informed consent occurred is not sufficient. It must be documented in the medical record.

  • All preoperative discussions about a procedure should be documented, including phone calls the night before a procedure.

  • The name of the procedure, its indication, and the probable risks and benefits should be explained.

  • There may be exceptions to the need to obtain informed consent, including emergency care when immediate treatment is required to prevent death or serious harm to the patient.