I can recall many years ago when patients would enter a dental office, sit quietly in a treatment room and allow the dentist to perform whatever treatment the provider deemed necessary. Then pay for the fee in full when leaving with no questions asked. These days are long gone in the dental practices of today.
Our patients nowadays are better educated, more informed about their treatment and much less trusting than the patients 35 years ago. They want to know what their options are, how much it will cost prior to having the treatment, what will happen if they don’t receive the prescribed treatment and how long they can prolong expensive restorative treatment before serious damage occurs.
This leaves our dentists open to future litigation should the patient complain of being inadequately informed of options or risks, especially if the practice has no documentation detailing this discussion took place.
Informed consent is defined as “a person’s agreement to allow something to happen, made with full knowledge of the risks involved and the alternatives.”
Our practices today need to understand that informed consent is no casual issue. When you look at procedures such as root canal therapy and extractions, these seem obvious when it comes to the need for informed consent. Dentists often overlook minor procedures such as minor restorations and local anesthesia that also require informed consent. Remember, informed consent not only protects the patient, but the doctor and practice as well. Any procedure that is “invasive or irreversible” requires informed consent.
Let’s talk about what information is needed for informed consent. It is not acceptable that a dentist document simple terms in the chart, such as “went over all risks of treatment and the patient understands.” Specific risks must be written down and patients must be given the opportunity to discuss these with the dentist, and then question the issues that they do not understand.
There are several key items that should be included for informed consent, although there is no mandatory format for how it should be written. Look for:
- A description of the procedure to be performed
- A list of the risks involved in the procedure
- Alternative treatment options and the risk of delaying or refusing treatment
- Wording to the effect that the patient agrees that they understand the risks involved in the procedure and has had the opportunity to discuss such risks with the dentist
- Signatures and dates from the patient and a witness
It is highly recommended that your practices have informed consent verbiage prepared for each procedure that is performed in the office. For those of you who do not feel comfortable putting together your own verbiage, it is best to either consult an attorney or contact a malpractice carrier. Most malpractice carriers will be happy to help with this endeavor.
Create informed consent records in Eaglesoft
Did you know that Eaglesoft allows you to create the informed consent record directly from the Treatment Plan screen?
Treatment plan procedures, radiographs, images and notes can easily be stored within this record. Auto notes can be created to easily add the necessary informed consent narratives, whether this contains a few or multiple paragraphs. All the necessary information can be stored in one record! The patient and an office team member (witness) can digitally sign the agreement, which can then be stored in SmartDoc. This will become a permanent part of the patient record.
Once your treatment plan is created with notes, services and images attached, from within the Treatment Plan window, click the “New” hyperlink to open the Informed Consent feature.
Use the Narrative field to add your specific narrative pertaining to the procedures within the treatment plan. Create multiple Auto Notes for these specific narratives to easily populate the Narrative field. Use a digital signature pad to capture the patient’s and witness’s signatures, choosing “Accept Signature” after each one. Click Create Consent and the Informed Consent can be sent to SmartDoc to be stored permanently in the patient record.
Please keep in mind that while the idea of informed consent is universal, laws may vary by state. If you have questions about the legality of informed consent in your area, you should consult your attorney.
This feature in Eaglesoft has been utilized by more and more of our customers over the years. Please contact our support team or a local Technology Advisor for any assistance. Remember to use our FAQ for more information on informed consent and improve your practice lifestyle with this great feature!