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

Health Literacy and Communication Techniques

View

Tips for foundation doctors, trainees and their supervisors

Tips for health care professionals

View

Shared decision making

Shared decision making

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