Top ten consent tips… continued

7. Record discussions regarding consent in the patient chart
Dentists should keep a record of all consent discussions in the patient chart. If a dentist obtains a patient’s verbal informed consent but makes no record of this interaction, a Court of law or a dental Councils may determine that there was a lack of consent. Overly general notations may also be insufficient for recordkeeping purposes. For example, vague references to “risks and benefits” may not indicate what information the patient used to make their decision. Chart entries should detail the discussed treatment, the specific information provided, the patient’s comments, questions, and decision, and whether consent was obtained for treatment.

8. Generate comprehensive forms that address the matter of consent
Dentists should consider implementing structural and administrative supports that may assist them in obtaining and recording consent. These supports may include office policies and standard forms. Procedures that are more serious should have detailed consent forms. New patient forms may contain a section asking who is permitted to provide consent and whether consent is required from any other individuals. It may also be prudent for dentists to include a section on the new patient form in which patients can provide their consent for the collection and use of personal health information.

• This topic was modified 7 months, 4 weeks ago by Vijay Baldwa.