Atlas · Plate XVIII · Ethics and Professional Responsibility · 02
Consent and records
Informed consent means explaining the condition, the proposed treatment, its risks, benefits and alternatives, and what happens without treatment. Opening the mouth is implied consent, and a refusal must be documented with the risks explained. Minors need a parent or guardian. Fix chart errors with a single line, the date and initials, never erasing or altering.
High-yield facts · 8
- Informed consent elements: the condition, the proposed treatment, its risks, benefits, alternatives (including no treatment) and the prognosis without treatment.T2
- Implied consent: actions show agreement (e.g., opening the mouth); express consent is stated orally or in writing.T2
- Informed refusal must be documented, including the risks explained.T2
- Consent for minors comes from a parent or legal guardian, except for emancipated minors or where state law allows.T2
- Correct record errors with a single line, the date and initials; never erase, white-out or alter after the fact.T2
- Electronic records keep an audit trail of every change.T2
- SOAP note format: subjective, objective, assessment, plan.T2
- Record retention periods are set by state law (commonly 6-10 years for adults, longer for minors). (varies by state)T2
Facts are written in our own words; each tag links to its source. Values marked "sources vary" differ between references, so check the one your program uses.