Maintaining Medical Records And Consent

A major responsibility of the physician and the medical assistant is to maintain an accurate and up-to-date record of the patient's care. Whatever style of record is used, the credibility of the medical record will be a key factor in any litigation. All matters related to a patient's care must be charted, and these charts must be an accurate reflection of actual care rendered and charges made. An act not recorded is generally considered an act not done. Charts that are incomplete or illegible are not easily defensible. Necessary corrections should be made by drawing one line through the error and placing the correction above it with the person's initials and date. All entries should be properly signed and dated, also. Consistency in the medical records becomes a powerful defense for the physician.

1) Informed Consent:
Documentation of informed consent becomes an important part of the medical records. Every patient has a right to know and understand any procedure to be performed. The patient is to be told in language easily understood:    
a. the nature of any procedure and how it is to be performed
b. any possible risks involved as well as expected outcomes of the procedure    
c. any other methods of treatment and those risks
d. risks if no treatment is given    

It is the responsibility of the health care provider to make certain the patient understands. If an interpreter is necessary, the physician must procure one.    
Often, consent forms will be signed if there is to be a surgical or invasive procedure performed (Figure 9-5). The medical assistant may be asked to witness the patient's signature and may be expected to follow through on any of the physician's instructions or explanations but is not expected to explain the procedure to the patient. The signed consent form is kept in the medical chart and a copy is also given to the patient.    

2) Implied Consent
Two circumstances related to consent are worth mentioning at this point. Implied consent occurs when there is a life-threatening emergency or the patient is unconscious or unable to respond. The physician, by law, is allowed to give treatment without a signed consent. Implied consent occurs in more subtle ways, also. The patient who rolls up a shirt sleeve for the medical assistant to take a blood pressure reading is implying consent to the procedure by the action taken.    

3) Consent and Legal Incompetence  
Consent for treatment is not valid if the patient is legally incompetent to give consent. Legal incompetence means that a patient either is found by a court to be insane, inadequate, or to not be an adult. In such instances, consent must be obtained from a parent, a legal guardian, or the court on behalf of the patient. Consent for treatment may be given only by the natural parent or legal guardian as determined by the court for a minor child, typically defined as one under eighteen years of age or the age of majority. An emancipated minor is one considered by the courts to be an adult. Emancipated minors may be defined as persons living on their own, who are self-supporting, who may be married, or who are in the military. They can legally give consent for treatment. Consent problems may arise when providing care to minors. Consent for medical care such as treatment of sexually transmitted diseases, pregnancy, alcohol or drug abuse, abortion, or birth control pose special problems. Some states allow minors to give their consent in these special situations.