Complaint management – handling the dissatisfied dental patient, part one

In all spheres, the risk management cycle is a three part process:

  • Awareness – finding out where the risks are.
  • Control – doing something about the risks to minimise them.
  • Containment – limiting the damage when things have gone wrong.

This article deals with containment. We’re all aware of the importance of early intervention in the context of disease and disorder, and we’re also all aware of the benefits of prevention. These concepts can be just as readily applied to avoiding, minimising and managing complaints but here we address when awareness and control either haven’t been applied or haven’t worked and we’re put into damage control mode.

Why would somebody complain? Reasons include:

  • They want an acknowledgement that something went wrong and an explanation of why.
  • They want an apology for the distress they experienced.
  • They don’t want others to have to face the same kind of problem that they did.
  • They want to improve the service for themselves or others in the future.
  • They want someone to be blamed, punished or held accountable for what happened.
  • They want retreatment, a refund or compensation.

Be mindful that not every complainant is coming from the same place in terms of motivation and how you handle the complaint may help to give you a strong insight into what lies at the heart of the matter and, therefore, what the appropriate strategy should be to manage it. Never assume that all patients complain for the same reason or because they desire the same outcome. A complaining patient may be motivated by one or more of the above but don’t immediately leap to the conclusion that the last two necessarily apply. With good management techniques many complaints never progress that far. Remember too that a complaint doesn’t necessarily mean that you did something wrong. Often it is the result of nothing more than poor communication and differing expectations.

The number of complaints which are just vexatious and made by people purely out to cause trouble is generally very low. Further, it is worth remembering that receiving a complaint, while it may not make your day, gives you an opportunity to understand a patient’s perspective and may help you to improve your service delivery. In the stress of the moment you may not realise it, but receiving a complaint can lead to positive outcomes for you if you are able to objectively analyse the circumstances, learn the appropriate lessons and adapt how you practice so as to reduce the risk of receiving more complaints in the future.

What are the avenues of complaint open to the dissatisfied patient? They may:

  • Confront the dentist or staff directly.
  • Write to the dentist.
  • Write to a statutory authority (in either the health or consumer sectors or both).
  • Engage a solicitor to correspond with the dentist on their behalf (often alleging negligence).
  • Engage a solicitor to lodge a Statement of Claim in the court system (civil action).
  • Complain to another dentist and seek their opinion and/or guidance.

It’s possible, of course, that a dissatisfied patient may not complain at all. They may just never come back to your practice. If that sounds like the easy way out for you be mindful that they may not voice their concerns to you but they will tell their family, their friends and possibly the whole suburb or town. Reputation is extremely important to most dentists, so the “disappearing patient” can still be problematic for you. Therefore, we really should welcome complaints to the extent that they give us the opportunity to manage the situation rather than having no control over it.

Every complaint is different so the approach to resolving it will differ based on several considerations:

  • The nature of the complaint (i.e. its seriousness and complexity).
  • The wishes of the complainant.
  • The issues the complaint raises.
  • How the complaint came to you.

The first avenue of complaint mentioned was for the patient to confront the dentist or staff directly. This one will almost invariably catch you unprepared and off guard so the following strategies are worth remembering, and they apply equally to yourself and your staff when confronted with a complaining – and possibly irate – patient.

  • Don’t ignore them. Nothing will inflame matters more quickly than if the person making the complaint feels they’re not even engaging the person to whom they’re speaking.
  • Don’t look away and don’t be distracted. Eye contact confirms your attentiveness.
  • Listen, don’t judge and don’t interrupt. When a patient expresses a concern, you need to understand what they’re saying and feeling (“active listening”) and then communicate back in your own words what you think has been said. When you do repeat the story back, keep to the facts and take the emotion out of things. You’re trying to serve as a mirror, but only mirror those aspects that are within your power to control. This technique allows you to validate the patient’s position without necessarily agreeing with it.
  • Be empathetic. Show your human side and acknowledge theirs. Get to the heart of the issue. Ask how you can help. When someone’s angry, there is no harm in a simple “Do you want me to help?” or, if the answer to that is self-evident, “Can I do anything to help?”

Do what you can in the moment to acknowledge the patient’s concerns, make a detailed record of the interaction as soon as possible after the event (verified by others who may have witnessed the encounter) and seek advice for ongoing management from your ADA and/or your insurer. Remember not to record the advice you receive from your ADA or insurer or lawyer in your clinical record. These confidential communications should be recorded in a separate document.

The second avenue of complaint for the patient is to write to the dentist. The advantage of this one is that you aren’t forced to think on your feet in the way that you are with a face to face complaint. You also have the opportunity to seek advice before responding at all. In a written response, it’s best to:

  • Acknowledge that voicing of concerns is appreciated.
  • Acknowledge the distress and the person’s experience.
  • Say what has been, or will be, done to investigate the complaint.
  • State what has been done or could be done to address the concerns.
  • Mention any changes or action taken (or that are being considered) as a result of the complaint.
  • Offer an opportunity to discuss further, with a choice of options (meeting, telephone, written).
  • If you’re comfortable in doing so, reassure the person that they can receive further service, if needed, without any concern about having made a complaint. Obviously such reassurance depends on the nature of the complaint.

Your advisor would be happy to guide you once you have prepared a draft response.

The third avenue of complaint available to the patient is to lodge their grievance with a statutory authority. You will eventually receive notice of this and be asked to respond. This response will initially be in writing and it is important that you do so in a way that maximises your chance of achieving a successful outcome. When you’re preparing your report:

  • Endeavour to control all negative emotions. Just because a complaint is made against a dentist does not, of itself, validate the complaint. It’s just the first part of a process and it’s then up to the dentist to defend their actions by providing their own reasonable version of the matter.
  • Always show respect and always attempt to assist. A courteous reply will often be appreciatively received.
  • The report should be couched in descriptive narrative terms and should be accurate, comprehensive and fair.

Guidelines on how to structure a response are included in the webinar. Please remember to run your response by your ADA advisor and your insurer’s appointed legal advisor before you submit it.

The fourth and fifth avenues of complaint open to a patient involve the engagement of a solicitor, either to deal directly with the dentist on the patient’s behalf or to lodge a Statement of Claim in the court system. The advice for handling these matters is very, very simple. Do not respond to any letter from a solicitor or any document from a court without seeking the assistance of your ADA advisors and the legal advisors engaged by your insurer. There is no higher requirement for “containment” than in circumstances such as this. Don’t respond to these matters yourself – the potential to get yourself “in deeper” is high and you will save yourself significant heartache by enlisting the support of those who are familiar with such matters.

The sixth avenue of complaint listed was for the patient to complain to another dentist and seek their opinion and/or guidance. This is where we all have a role to play in containing the fallout which may follow once a patient is dissatisfied. If you are ever in the position of being that “second dentist” there are some points to keep in mind when a patient comes complaining to you, remembering of course that their grumbles may well be entirely justified. The other angle to consider in all of this is of the patient who was quite happy with their previous dental treatment until comments were made by another dentist and this precipitates a complaint which may otherwise never have been made. Some tips, then, for the “second dentist”:

  • If you come across a case where work done recently is going to need to be replaced, ask permission from the patient before contacting the previous dentist to research how things have got to that point. Point out the clinical problems that exist in a calm manner without criticising others.
  • Be on alert so that, when asked to give an opinion on treatment that hasn’t had a satisfactory outcome, you don’t pass comment on the standard of care of the treatment provided by another. Of course our patients pay well for our services and care and we shouldn’t turn a blind eye to problems which exist. All patients at all times are owed a proper and professional diagnosis. If, however, you find yourself in the position of being the “second dentist” your aim should ideally be a clear discussion with the patient with explanation and co-discovery of problems that are apparent at the time of consultation. No more, no less.
  • Criticism of previous work is non-productive and gives the entire profession a negative bias that can be difficult for the next operator to overcome.
  • Don’t falsely criticise others in an attempt to justify the treatment you’re recommending. You’ll never look “bigger” in a patient’s eyes by making the previous dentist look “smaller.”
  • In any discussion with a patient and their support person the dental practitioner should take care not to state or agree that another health care professional is liable for any harm which may have been caused to the patient.
  • Remember that one day you may be in the position of having your work criticised by others so be honest with the patient and fair to your colleagues.

By whatever means a complaint is received, there are strategies/actions/policies to keep in mind and apply wherever possible to achieve the best possible outcome:

Timeliness

When dealing with a complaint, no matter how trivial, time is of the essence. An irate patient who doesn’t receive a prompt response may feel ignored and be more likely to take matters further. Therefore:

  • Respond as soon as possible to the complaint, even if it’s just to explain the process and give a commitment to a certain timeframe.
  • Stick to the timeframe given.
  • Keep the complainant informed.
  • Give reasons for any delays.

Address all aspects of the complaint

  • Provide a full response so that important issues are answered and the complainant can see that the complaint has been taken seriously.
  • Explain the process of investigation.
  • Acknowledge areas of disagreement or varying accounts without dismissing what the complainant has said.

Remember

  • Try not to be defensive.
  • Acknowledge the distress of the complainant.
  • Apologise if appropriate, but in any event be sympathetic.
  • Acknowledge any errors that did occur.
  • Try to understand the situation from the complainant’s perspective.
  • Find out what will assist the complainant to resolve the matter. Examples could include a written response, a phone discussion, changes in policy or procedures, a meeting.
  • Avoid official or technical language, jargon and clichés.
  • Consider cultural background and sensitivities and the possible use of an interpreter if necessary.

Provide your perspective

If a written complaint has been received by a statutory authority you’ll generally be notified about the complaint. You’ll receive a copy of the complaint and will be able to respond to it before a decision is made about the action to be taken on the complaint.

Indicate that lessons have been learned

Outline:

  • What happened.
  • How it happened.
  • What’s being done to stop it happening again.
  • That you’re sorry that it happened.

On this last point, some people have real issues with saying sorry. There has been a historical reluctance to offer an apology to a patient on the basis that it may be misconstrued as an admission of fault. Dentists have often harboured the concern that if they offer an apology to the patient, the patient will rely on that apology to establish a case in negligence before the civil courts. Legislative reform across all states has put this concern to rest. Put simply, an apology is not an admission of liability for the purpose of civil proceedings.

The effect of an apology should not be underestimated. It is the DDAS experience that many civil claims would not have eventuated if a carefully worded, timely and sincere apology had been provided to a patient. Very often a patient will simply feel wronged and want acknowledgement. If ignored they’ll often take matters further. If for no other motivation, a further reason to make an apology is that regulatory bodies tend to place weight on an apology when determining the outcome of a disciplinary matter.

Seek support

Always do this, and do it early. It is not just important to be timely with the patient – you need to be timely for your own wellbeing. Consult with:

  • Your state branch of the ADA.
  • Your insurer and their appointed legal advisors.
  • Any relevant senior person in your workplace such as a supervisor or manager.
  • If you’re employed in the public sector, you may wish to contact the Complaints Manager of your hospital or Local Health District.
Key Points

· A complaint does not necessarily mean that you have done something wrong.

· Receipt of a complaint can be a valuable learning experience.

· Good complaint management strategies can prevent escalation of a matter.

· Take time to understand a patient’s perspective so your response can be appropriate.

· Don’t record any advice you receive from your ADA advisor or a lawyer appointed by your insurer in the patient’s clinical record. These confidential communications should be recorded in a separate document.

In the second part of this article we provide a rationale behind some of the strategies recommended and look at three common scenarios and the thought processes to apply when considering how to manage the situation.

By Dr Craig Brown – ADA NSW Branch Peer Advisor

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    Record keeping requirements.

    Clinical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting topic for health practitioners to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many health practitioners would benefit from learning more about good record keeping.

    Clinical records and insurance claims

    Clinical records can impact insurance claims in two ways:

    1. Poor records which lack detail can lead to incorrect clinical decision making and poor clinical outcomes for the patient and therefore patient complaints.
    2. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

    Why keep detailed clinical records?

    1. Continuity of patient care

    It’s not uncommon to hear health practitioners claim they can remember the details of patient consultations. However at Guild, we regularly see examples where practitioners haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the patient. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated a patient in the past.

    It’s also important to be sure you refer to the information within the patient’s record. Patients can suffer harm when information, such as allergy details, is overlooked or forgotten about and therefore the patient isn’t treated accordingly.

    2. Regulatory requirement

    All Australian Health Practitioner Regulation Agency (Ahpra) regulated practitioners need to be well aware of their many regulatory requirements; good record keeping is one of these. Each profession’s Code of Conduct contains information about a practitioner’s obligations and requirements regarding record keeping. Several Ahpra National Boards have also created a separate document on guidelines for clinical records which further explains what’s required.

    It’s the responsibility of every registered health professional to make themselves aware of and comply with the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.

    3. Defence of a complaint

    If there’s any allegation of wrong doing made against a practitioner, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the practitioner will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a practitioner’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

    4. Funding audit

    Funding providers, such as private health insurers, regularly review the rebates they pay for healthcare and can conduct audits to be sure health practitioners are billing appropriately.

    It’s not uncommon for a health practitioner to receive a request from a funding provider to produce clinical records to justify their billing practices. This is another example of when a practitioner needs documented evidence of what they’ve done and why. If the reasons behind treatment, and therefore billing, isn’t clear, funding providers can demand repayment.

    Record keeping requirements

    What to record?

    The key question many health practitioners ask when it comes to clinical record keeping is ‘how much detail do I need to record?’. Practitioners should refer to their Code of Conduct, as well as the guidelines on record keeping if one exists, to better understand the detail required in a clinical record.

    Exactly what to include can vary according to the type of health profession as well as the specifics of the patient’s condition and treatment. However, generally records should include, but aren’t limited to:

    • Patient identifying details and contact information as well as health history
    • Name of the consulting practitioner and the date of the consultation
    • Reason for the patient presentation
    • All examinations and investigations conducted and their results, even if there is no abnormal finding
    • Diagnosis and treatment plan
    • Consent to treatment
    • Treatment provided and the patient’s response
    • Any items supplied, or instructions given, to the patient
    • Referrals to other health professionals

    In some cases, it’s worth noting what didn’t occur as well as what did. For example, if a patient has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined. If it’s simply left out of the record, it would appear that it wasn’t discussed as a treatment option.

    When a practitioner is unsure if they have included enough detail, they should ask themself whether or not another practitioner could read the record and understand the full picture of what took place and why, without the treating practitioner filling in any gaps. If the full story isn’t there, there isn’t enough detail.

    Professional and objective

    Clinical records need to always be professional and objective. Negative comments about the patient can be included, however, this must be professional and only when this is relevant to the treatment being provided. This may occur in situations where the patient isn’t complying with instructions and this is detrimental to their health. However, it’s important to remember that clinical records can be accessed and read by a number of people, including the patient and your regulator, so always be mindful of the language used. The language used should match the professional language a health practitioner would use when speaking to the patient during a consultation.

    Using Artificial Intelligence

    As with many other parts of our lives, the use of artificial intelligence (AI) is creeping into record keeping practices more and more all the time. And while there are numerous potential benefits of using AI, there are also risks that health professionals need to understand and manage. The first step in this requires practitioners thoroughly research any AI tool they intend to use and be sure they understand how they work, particularly in relation to the storage and use of information input into them.

    The task of creating appropriate clinical records can’t be left to AI; practitioners must be sure they review any AI‑generated information to be sure it’s detailed and accurate. And when doing this they must keep in mind that AI isn’t perfect; it will at times leave out important information and even make things up. It’s also important to be sure patients are aware of the use of AI. When patient data is being input into an AI tool or if consultations are being recorded, informed consent is a must.

    For further information about the use of AI in healthcare, refer to guidance available from Ahpra that can be found at www.ahpra.gov.au/Resources/Artificial-Intelligence-in-healthcare.

    Disposing of records

    There’s no requirement to dispose of clinical records, and from a risk mitigation perspective, it’s advisable to keep them for as long as you can.

    In New South Wales (NSW), Victoria and the Australian Capital Territory (ACT), it’s required that records for an adult patient are kept for 7 years from the last date of entry. For a patient who was under 18 years of age when the last record was made, those records need to be kept until that patient turns 25 years old. Other states and territories don’t have specific legislation regarding time frames for keeping health records. However, it’s recommended that practitioners in those states and territories adhere to the requirements for NSW, Victoria and ACT.

    There’s varying legislation across the different states and territories regarding processes to adhere to when disposing of records. It’s recommended practitioners make themselves familiar with what’s required, if intending to dispose of records, and seek independent legal advice if needed or speak to your professional association.

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  •

    Managing patient expectations in dentistry

    Listen or download (mp3) the audio reading of this article, brought to you by Guild Insurance

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    It’s well recognised that patients don’t necessarily complain simply based on their clinical outcome. Most dentists will have heard of or seen situations where a patient has experienced an outcome which wasn’t ideal yet wasn’t particularly poor, however the patient has been quite annoyed with the outcome and has lodged a complaint.  On the other hand, there are many cases of patients who have experienced quite poor outcomes yet have chosen to not complain.

    There are many reasons why the above may occur, some which are easier to identify than others. All patients are different and human behaviour isn’t always predictable.  Good communication and the relationship between the patient and dentist will greatly influence the likelihood of a complaint.  One other very important factor is the expectations of patients.

    Patient expectations

    Many patients will go into dental appointments with some level of expectation regarding their likely outcome. They may have a very clear and detailed outcome in mind or it may be more broad and open.  Most importantly, some of these expectations will be realistic, however others won’t be.

    Unrealistic patient expectations pose very real challenges for dentists. If a patient undergoes treatment which they have unrealistic expectations about, it’s unlikely those expectations are going to be met simply due to them being unrealistic.  If a patient’s expectations haven’t been met, it’s likely the patient is going to be unhappy or dissatisfied with the treatment.  Those unhappy and dissatisfied patients are the ones more likely to complain about the treatment and expect further corrective treatment or compensation.  It’s therefore vital that dentists do all they can to help the patient fully understand treatment and the likely and possible treatment outcomes before treatment begins.

    Creating realistic expectations

    A key step in making sure a patient has realistic outcomes regarding treatment is to have an open and honest conversation with them. This will not only provide the patient with further information about their treatment, but will also give the dentist a clearer understanding of the patient’s expectations.  A dentist’s clinical skills are vital to what they do, however effective communication goes a long way in providing positive outcomes.

    To assist a patient to have realistic expectations, dentists must ensure they explain the treatment and outcomes using simple, clear terms. Technical clinical language should be avoided as many patients won’t understand this.  Dentists should also consider how they tailor their language and the information for each individual patient.  For example, a person with language or literacy challenges may need information presented in a more detailed manner than other patients.  Dentists should also consider using diagrams, pictures or models to assist with understanding where appropriate.

    When discussing treatment with a patient, it’s important that dentists don’t make assumptions about what the patient will or won’t understand. It’s easy for dentists to become so familiar with what they do and know that they sometimes forget how foreign that knowledge can be to other people.  Patients will have varying degrees of knowledge and experience regarding dental treatment.  Therefore, what they understand about their treatment will also vary.

    When a patient attends a dental clinic and requests a particular form of treatment, this is an occasion when a dentist should be especially mindful of the patient’s expected outcome. When a patient has requested a form of treatment, the patient has clearly formed a decision around what treatment they need to get the outcome they desire.  What they’re requesting and expecting may be reasonable and realistic, however in some cases it may not be.  When presented with this situation, dentists need to be sure they don’t rush into providing the patient with the requested treatment.  As with all patients, there needs to be a thorough assessment and diagnosis process.  Then the patient is to be provided with their treatment options, as well as the risks and benefits of those options.  There may be treatment options which are more suitable for that patient which the patient isn’t aware of.  The patient also needs to be made aware of the likely treatment outcomes for each of those treatment options.

    The dentist needs to be sure the patient has all required information before consenting to treatment and this includes understanding the likely outcomes. A patient requesting particular treatment doesn’t alter this required process.  And dentists need to remember that they’re always responsible for the treatment they’ve provided, regardless of whether it was requested by a patient.

    In summary…

    Dentists should be doing all they realistically can to improve the outcomes for their patients and reduce the likelihood of poor outcomes and complaints. An important step in this process is making sure patients have realistic expectations regarding treatment outcomes.  Dentists have a very important role in using their clinical knowledge in conjunction with practical terminology to assist patients to develop realistic expectations.  Dentists need to remember this is of great benefit to both themselves and their patients.

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    Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them. This article contains information of a general nature only, and is not intended to constitute the provision of advice.
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    Importance of Informed Consent

    All health practitioners would be well aware of their requirements to obtain informed consent from their patients before assessment or treatment takes place.  However, Guild Insurance’s vast experience in managing claims made against health practitioners has highlighted that many practitioners don’t meet all their informed consent requirements.

    What is informed consent?

    There is an explanation about informed consent in the Code of Conduct for each of the professions regulated by AHPRA.  In this document, informed consent is defined as ‘a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved’.  This statement highlights the difference between consent and informed consent.  If a patient hasn’t been made aware of the benefits and risks, their consent isn’t informed.

    Informed consent isn’t just required for treatment. Depending on the nature of the healthcare being provided, informed consent should also be obtained for assessment. 

    Informed consent and insurance claims

    Informed consent can feature in insurance claims against practitioners in a couple of ways.

    It’s not uncommon when a patient is unhappy following treatment for them to allege they weren’t made aware of the risks when they consented to treatment.  Quite often they will allege the treatment was negligent and has resulted in harm or suffering.  They then add that had they been informed of the possible risks, they wouldn’t have consented.

    In other cases, patients may not make any allegation about consent, their complaint might solely focus on the clinical outcome, yet when their claim is being managed it’s found that they didn’t give their informed consent prior to treatment being provided.  When this occurs, it makes it challenging for Guild to prove that the practitioner has treated appropriately and met their requirements.

    The informed consent conversation

    Informed consent requires a conversation between the treating practitioner and the patient.  This conversation needs to occur prior to assessment and treatment. 

    The conversation must:

    • detail the recommended assessment and treatment as well as alternate treatment options
    • include the expected benefits of that treatment
    • provide information about the risks of the treatment
    • allow time for the patient to ask questions
    • be held in language which can be understood by the patient which means practitioners should avoid technical clinical language.
    • take place in a private area where the patient will feel comfortable being open and honest about their health situation.
    • be tailored to that individual patient and their unique clinical needs

    Recording informed consent

    It’s imperative that practitioners make a note in the clinical record regarding the patient providing their informed consent.  This needs to be more than ‘IC given’.  The record needs to show what treatment options and risks were discussed as well as any questions asked by the patient.  The record should also show what the patient consented to as well as what they didn’t consent to where relevant.

    The informed consent form

    One area which leads to some confusion about informed consent is how to use an informed consent form.  Having a patient sign a form is seen as a quick and simplified way of having a patient provide their informed consent and keeping a record of that.  However, they are unfortunately too often used inappropriately. 

    Signed forms aren’t a requirement.  While recording consent is required, this doesn’t need to be done using a form.  Notes in the clinical record are sufficient.  However, signed forms do provide additional evidence if there is an allegation that informed consent wasn’t given.

    Forms can’t be used to replace the informed consent conversation.  A patient can not read a form and gain the same level of understanding as they would from a conversation with the practitioner.  Nor can they ask questions of the form. 

    A form should only be signed after the conversation with the practitioner has been had and the patient understands what it is they’re consenting to.  Patients are occasionally asked to sign consent forms at reception before they’ve seen the practitioner.  As there has been no assessment or discussion about treatment at this stage, this can’t be considered informed consent as the patient hasn’t been informed.

    Some practices combine new patient forms with the consent form.  This isn’t ideal as the two forms serve different purposes.  Also, having them on the one form encourages patients to sign the consent form at reception before they’ve seen the practitioner.  Therefore, they should be divided into two separate forms.

    Informed consent is not a one-off event

    Practitioners regularly ask how often their patients need to give informed consent.  There is no set time frame for when informed consent conversations or signed forms need to be repeated.  The requirement is that when a patient is receiving any assessment or treatment, they need to have given their informed consent to this.  Therefore, informed consent should be an ongoing process; it’s a continual conversation with patients during consultations.  And when there is any change in the treatment being provided, or if the patient has returned following a period of absence, informed consent needs to be revisited.  A general ‘consent to all treatment’ for the life of the therapeutic relationship is not appropriate.

    Informed financial consent

    As well as consenting to assessment and treatment, patients should also give their informed financial consent.  This means they need to be provided with information about the expected cost of treatment before this treatment commences.

    In summary…

    There is no one right way to undertake an informed consent conversation and process.  Practitioners must adapt what’s discussed for the patient they’re treating and that patient’s unique circumstances.  However, what must occur in all cases is that the patient is informed of and understands the proposed treatment, alternate treatment options and the risks involved.  Only with this information can they give their informed consent.  The practitioner must also be sure to make a record of this informed consent discussion in the clinical record.

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