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Best practice in documentation

On consent forms:

  • Avoid abbreviations as these are not always clearly understood by everyone.
  • Aim to use both medical and lay terms if there is room on the form.
  • List risks that have been discussed with the patient.
  • Consider reconfirming the consent with the patient.

In the clinical notes/patient record:

  • The different options offered to a patient, these should include no treatment.
  • The risks and benefits discussed.
  • If the patient has a particularly strong reaction or feeling about a treatment/risk, write it down.
  • What informational materials were offered/accepted/given.

Medical Consent Download Checklist

See also

Health Literacy and Communication Techniques

Tips for foundation doctors, trainees and their supervisors

Tips for health care professionals

Shared decision making

Shared decision making

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