Guidelines on Record Keeping and Informed Consent

Guideline on Record Keeping and Informed Consent.

Kris Hendricks, Lit Review 12/18/09

Records

Just copy the appendixes and use them. See, how easy was that?

Purpose: assist practitioners in creating a comprehensive patient record, but this is not meant to be the “standard of care”

Each patient should have an individual record, most of this seems intuitive at this point so there isn’t much to say.

In order to not overlook important details in your records, use the appendixes included to make sure your records have all needed elements.

Everything that is done, every correspondence, every mediation used, basically everything must be recorded.

In depth medical and dental histories and risk assessments too.

Informed Consent

Process of informing pt or custodial parent/guardian with relevant info regarding dx and tx needs so an educated decision can be made.

The ADA code of ethics says: “the dentist must inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”

Every person has the legal right to determine what happens to his or her own body.

States differ on their interpretation and expectations of informed consent. \

As we know the accompanying person of a minor patient may or may not legally be able to give informed consent.

Some states require written consent before treating a patient, but even if not mandated, it’s a smart idea.

Some states will allow oral conversations documented in the medical record.

Consent form should include proposed therapy, risks, benefits and possible alternative therapy.

Forms should utilize simple words and phrases. The lay person --or in the case of some parents extra-lay person—should be able to understand the forms.

Courts have decided that the use of overly broad terms like “all treatment deemed necessary by the doctor” are too unspecific and do not constitute informed consent.

There are lists of essential elements in the handbook.

Forms need to be procedure specific, and you will need different forms for different procedures.

Additional consent for protective stabilization and sedation should be used separately.