Two Continued Sources of Risk for Physicians: Informed Consent and Advanced Practice Professionals

The goal of CAP’s Risk Management and Patient Safety Department is to prevent patient injury, prevent adverse events, and reduce claims by educating physicians to utilize risk strategies across the continuum of care. We do this by identifying the risks in our members’ practices through claims analysis, hotline calls, and practice visits. This risk identification results in the creation of risk tools, forms, and guidelines that can be used by the physician in his or her office or hospital practice. Recently, our investigation revealed two continued sources of risk for our members: Informed consent/informed refusal and lack of supervision of advanced practice professionals. 

Below are the steps you can follow to improve your consent process:

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  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 his or her confidence in the informed 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. Retain a copy of the informed consent/refusal given to the patient 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.

A second example of a current challenge for many physicians is the use of nurse practitioners and physician assistants in their practices. Supervising physicians receive claims against them when their supervised advanced practice professionals have an adverse event or a claim. Many of the problems stem from simple lack of communication. The common response to a majority of these cases is, “I didn’t do anything wrong, my PA or NP didn’t keep me in the loop.” It is vitally important for the supervising physician to have open communication with his or her staff. By being an active component of the physician/PA or NP team, you can ensure they understand and are aware of your practice's policies and procedures.

Below are some safeguards you can implement to protect your practice:

  1. When hiring a PA or NP,  complete a  Delegation of Services Agreement or Nursing Standardized Procedure for each practitioner. These are a written outline of what each professional can and cannot do in your practice.
  2. Board requirements for supervising a PA or NP differ slightly. Get familiar with the requirements for any practitioner that is brought on board.
  3. Remember, there are limits to the number of advanced practice professionals that may be supervised by one physician. Keep the ratio 1:4 in mind, one physician per four advanced practice professionals.

At CAP risk management, we are here for you. If you need advice or have questions regarding medical professional liability risk, need a form or guidelines, or would like to request a practice visit, please call the CAP Hotline at 800-252-0555 or email us at


Ann Whitehead, JD, RN, is CAP’s Vice President of Risk Management and Patient Safety. Questions or comments related to this article should be directed to