How Should The Informed Consent Process Be Documented In The Medical Record?
The informed consent process is documented in two separate ways in the medical record. The first way is by obtaining the patient’s signature on an appropriate consent form following the necessary disclosure of information upon which a patient can give his or her informed consent. The second way is by documenting the informed consent process in the patient’s medical record. This can be an entry in the office records maintained by a physician or by a progress note in the hospital record.
