While the fine points of documentation may vary by situation and practitioner, it is important to remember that accurate and detailed documentation is medico-legally valuable. A simple phrase such as, “Risks, benefits, and alternatives to treatment discussed, including, but not limited to…” may be a useful addition to an emergency department chart.

Documenting specific topics raised by the patient and noting witnesses (including patient’s friends and family, as well as staff) may further strengthen the chart.

In Conclusion

It is important to remember that proper informed consent (the process, not the form) is a critical part of the delivery of care. Review of case law reveals that documentation of the informed consent process is a critical part of risk management. Because many hospitals rely on a standard boilerplate consent form, careful documentation of an excellent informed consent discussion will improve the medico-legal strength of the record.

Dr. Nordlund is an adjunct professor of Emergency Medicine at the Michigan State University College of Osteopathic Medicine and is admitted to the State Bar of Michigan.

Dr. Koslow is an assistant clinical professor of emergency medicine at Tufts University School of Medicine, staff physician at Steward Good Samaritan Medical Center, and a member of the ACEP Medical Legal Committee.

About LegalEase

ACEP’s Medical Legal Committee sponsors these articles addressing medical-legal topics of interest to ACEP members. If you have legal questions you would like discussed in print, please submit them to Dr. Louise B. Andrew at acep@mdmentor.com. Please don’t disclose any details of a pending legal case. If you need advice regarding litigation stress, please contact Marilyn Bromley, ACEP Director of EM Practice, at 800-798-1822, ext 3231 or mbromley@acep.org.