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.