Article: Using informed consent forms vs. progress notes.

Using informed consent forms vs. progress notes

While not required, forms ensure accuracy

If its not documented, it didnt happen. That applies to informed consent as well as all other activities associated with same-day surgery. Even though obtaining informed consent is a responsibility of the surgeon, all same-day surgery managers should make sure the consent is documented in a manner that clearly meets accreditation, state, and federal guidelines, says Jean S. Clark, RHIA, director of health information services at CareAlliance Health Services in Charleston, SC.

Although there is no requirement that a separate form be used to document informed ...

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