■ Physician-patient:

Communicating effectively with patients to optimize their care

Documentation of consent discussions

Type of activity: Quick activity

Activity summary

These 6 short scenarios illustrate some of the many situations in which physicians commonly document patient consent discussions and what should generally be documented. The facilitation questions focus on helping learners to identify the key information that should be documented, including a description of the proposed treatment, alternatives to treatment, the option of no treatment, material and special risks, and patient questions.

Scenarios

Scenario 1

A 45-year-old male is admitted with a suspected small subdural hematoma and is scheduled to have a CT scan of his head in the morning. The nurse calls you and says the patient declines to stay overnight as he hates hospitals. He is fully alert and oriented.

How would you approach this situation? How would you document this in the medical record?

Scenario 2

Your staff physician prescribes a medication that is potentially teratogenic for a 19-year-old female with acne. He asks you to talk to the patient and give her the prescription.

What are the differences between material and special risks? Can you identify the material risks in this specific case? What could be a special risk in this case?  How would you document your consent discussion?

Scenario 3

A 25-year-old female has a large wound on her finger but declines to have it sutured because she states she is afraid of needles.

How would you approach this situation? How would you document this in the medical record? 

Scenario 4

An 88-year-old male with severe dementia and now suffering from pneumonia is transferred from a nursing home. His substitute decision-maker does not want him admitted to hospital or treated with antibiotics and wants him sent back to the nursing home.

How would you approach this situation? How would you document this in the medical record?

Scenario 5

A 35-year-old female is in labour. Your staff physician has asked you to perform a pelvic examination. The patient declines to have a trainee examine her.

How would you approach this situation? How would you document this in the medical record?

Additional resources

CanMEDS: Medical Expert, Communicator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.