Introduction
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.