How to document informal conversations for potential malpractice claims?

Question

As a nurse working in a group home for individuals with developmental disabilities, I accompanied a patient to a pre-operation appointment where the surgeon assured us that her preexisting medical condition would not increase surgical risks. Post-surgery, she experienced complications that were later attributed by the same surgeon to her preexisting condition during an informal hospital conversation. If faced with a similar situation, what actions and documentation practices should I follow to protect my client's ability to file a medical malpractice claim if necessary, particularly when conversations vary from formal appointments to informal discussions?

Jonathan R. Ratchik · Answer

In an action for informed consent, the physician has a duty to advise the patient of the risks, benefits and available alternatives to the proposed treatment. Although the patient developed post-surgical complications that the physician claimed were unlikely, the question is whether a reasonable person in that patient's position would have consented to the procedure if given appropriate information. With regard to documenting informed consent, apart from the informed consent form itself, the group home likely has procedures that caregivers are required to follow when it comes to documenting care. Any documentation relating to informed consent should be part and parcel of the patient's chart.

Tim Akpinar · Answer

As my colleague correctly points out, informed consent is generally covered by forms found in the patient chart. It could be part of a large package of forms, from medical authorizations to assignment of benefit forms. Most major facilities use informed consent forms that are comprehensive in their scope. Good luck

Q: How to document informal conversations for potential malpractice claims?