Informed Consent and Informed Refusals Decoded: Healthcare Risk Management Week Part 1

Healthcare Risk Management (HRM) week starts June 18, 2018. In preparation for the week, it is important to understand the role risk management plays in creating a safe and protected physician-patient relationship.

CAP’s Risk Management and Patient Safety Departments goal is to prevent issues by utilizing risk strategies across the industry, reducing adverse events and claims. This includes increasing our member’s awareness by researching old and new trends, using examples of risk and adapting methods and strategies that can be used as resources and tools for physicians, practitioners, and their staff.

[Webcast] MACRA, MIPS, QPP: Maximizing Your Participation and Reimbursement
In today’s ever changing healthcare climate, maximizing revenue while providing quality care for patients is more important than ever. An understanding of the Quality Payment Program (QPP) can be daunting but is necessary for navigating the current healthcare environment. Watch our latest webcast where we answer your questions about MIPS and QPP.

An example of a current problem that continues to occur is informed consent and informed refusals. Below are the steps you can follow to protect your practice:

  1. Informed consents and refusals should name the physician educating the patient. It is recommended that the physician who completes the consent or refusal sign the form to ensure their confidence in the inform consent or refusal that took place. Although not required, the physician’s signature, along with a witness’ signature, can be the key in determining that the patient understood and signed the consent or refusal on his or her own accord. Documentation in copy of the informed consent/refusal given to the patient and scanned into the chart.
  2. It should be completed in the practice before hospital pre-op and maintained in the patient’s office record.

  3. The form should list common terminology and medical terminology, specific and general risks for the procedure, alternatives to treatment, and risks of not getting any treatment.

At CAP, we are here for you. If you think you are at risk, call the CAP Hotline at 800-252-0555 to address the immediate needs of your practice. You may also contact us if you would like to schedule a practice survey visit, or to get the tools your practice may need.


Authored by Steven Blackburn
Senior Risk Management & Patient Safety Specialist