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Informed Consent: an Overview

5 years ago

We know you’ve heard the term “informed consent” many times before – and chances are you’re familiar with what it means – but we thought it’d be a good idea to give our policyholders a little “refresher” on the term so they’re absolutely sure they’re doing everything they can to be fully protected in the event of a lawsuit.

What is Informed Consent?

Informed consent is the legal doctrine affirming a patient’s right to determine and control his or her own medical treatment. In essence, it is the discussion that takes place between the physician who is rendering care and the patient. Specifically,

Procedures Requiring Informed Consent

Although it is always good practice and important for a physician to explain to a patient the treatment he is rendering, obtaining an informed consent in New York State is only statutorily necessary if there is non-emergency treatment, procedure, or surgery, or, if a diagnostic procedure involves an invasion or disruption of the integrity of the body. A physician is not required to procure an informed consent for an emergency. If a physician is in doubt as to whether a diagnostic procedure requires informed consent, it is a good idea to err on the side of obtaining an informed consent.

Informed Consent and Minors

Generally, the New York statute states that children under the age of eighteen are minors. And, when the patient is a minor, consent for his medical treatment must be obtained from the parent or legal guardian. There are some exceptions:

Additional Considerations

In addition to having the consent formed signed, physicians should always write a note in the chart after they have had an informed consent discussion with the patient. The note should be dated and should include the following, “The risks, benefits, and alternatives, including no treatment, were discussed with the patient. The risks discussed included, but were not limited to . . .” and list a few of the most severe and a few of the most frequent risks or complications. Finally, note that “the patient understood, had all his/her questions answered, and consented to the treatment or procedure.” This type of documentation will confirm and be evidence that a discussion actually took place with the patient.

Learn more about informed consent through these resources from the MLMIC library, and be sure to stay tuned to the MLMIC blog for more “refresher courses” in common terms and practices.


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