The Signature Is Not Enough
The Importance of Properly Completed Consent to Treatment Documentation
Obtaining informed consent is a fundamental requirement of veterinary practice. A signed Consent to Treatment form, however, does not necessarily establish that informed consent was appropriately obtained or documented.
Gaps in consent documentation can have significant medico-legal implications, particularly when a postoperative complication results in a complaint or professional indemnity claim.
A recent matter referred to the Veterinary Defence Association (VDA) demonstrates the importance of complying with established consent protocols and the potential consequences when essential information is omitted.
A Case in Point
Fluffy, a male dog presenting with urinary calculi, underwent surgery under the care of Dr A.
The procedure included a cystotomy and the removal of a penile urethral calculus, along with additional urinary calculi. Intraoperative radiographs were taken, with abdominal packing used at this stage. It was later suspected that a surgical swab had inadvertently been retained during this stage of the operation.
Approximately five weeks later, Fluffy required further surgery. During this procedure, Dr B discovered a retained surgical swab within a granuloma.
Following this discovery, Fluffy’s owner, Mrs X, lodged a complaint regarding the initial surgery and the subsequent treatment required.
A review of the clinical records revealed several concerns. There was no documented swab count, surgical checklist or formal counting protocol. Furthermore, the operative notes made no reference to the use of abdominal packing, flushing procedures or swab counts.
Dr A acknowledged that the swab may have been retained during the original procedure but could not explain why it had not been identified during flushing.
While these findings were relevant to the clinical complaint, a separate medico-legal concern emerged during the review of the Consent to Treatment form.
Although Mrs X had signed and dated the form, neither the proposed surgical procedure nor a provisional diagnosis had been recorded.
The case therefore raised two distinct concerns: the circumstances surrounding the retained surgical swab and whether the consent documentation complied with the VDA’s Consent Protocol.
Informed Consent Is More Than a Signature
Informed consent requires an appropriate discussion of the proposed treatment, its material risks, reasonable alternatives and relevant consequences.
The consent form should provide documentary evidence of the treatment authorised and support the information recorded in the clinical notes.
A client’s signature alone does not establish the scope of the authorisation provided or demonstrate that the necessary information was communicated.
Informed Consent Requirements
Members are required to ensure that the VDA-approved Consent to Treatment form is completed before treatment commences, including the recording of a considered estimate of costs and the proposed procedure or provisional diagnosis.
A consent form that has been signed and dated but omits the proposed procedure or provisional diagnosis does not comply with these requirements.
Implications for Professional Indemnity
Failure to comply with established consent protocols may have implications beyond the assessment of clinical liability. Where compliance with specified consent requirements forms part of professional indemnity arrangements, deficiencies in documentation may affect an insurer’s determination of cover.
A deficiency in consent documentation does not automatically establish clinical negligence or result in the refusal of indemnity. These are separate matters requiring individual consideration.
Nevertheless, where indemnity is declined, the financial consequences for the veterinarian may be substantial. Compliance with consent protocols must therefore be regarded as an essential component of professional risk management.
Clinical Records and Consent Documentation
Consent documentation should be supported by contemporaneous clinical records detailing relevant discussions, recommendations, decisions and treatment undertaken.
In Fluffy’s case, deficiencies in the consent form were accompanied by incomplete surgical documentation, including the absence of recorded swab counts and procedural checks.
Although these represented separate concerns, both were relevant to the subsequent assessment of the complaint.
Comprehensive clinical records provide evidence of the veterinarian’s clinical reasoning and of the information communicated to the client. Inadequate documentation may leave the practitioner dependent upon recollection rather than contemporaneous evidence.
Preventing Routine Omissions
Consent documentation is frequently completed during patient admission, often alongside several other administrative and clinical procedures.
The routine nature of this process should not diminish the importance of ensuring that all required information has been recorded. A signed and dated form should not be considered complete where essential details, including the proposed procedure, provisional diagnosis or estimated costs, have been omitted.
Consent documentation should be reviewed before treatment commences to ensure compliance with the applicable requirements.
Before Treatment Commences
Veterinary professionals should verify that:
- The client and patient have been correctly identified.
- The proposed procedure or provisional diagnosis has been specified.
- A considered estimate of costs has been documented.
- The nature of the treatment, material risks and reasonable alternatives have been discussed.
- Appropriate client authorisation has been obtained and dated.
- Relevant discussions and decisions are recorded in the clinical notes.
Where additional procedures or material changes to the treatment plan become necessary, further authorisation should be considered in accordance with the clinical circumstances and applicable professional requirements.
Responsibility for Obtaining Consent
Veterinary nurses, technicians and administrative staff may assist with the preparation and administration of consent documentation. Nevertheless, the veterinarian remains professionally responsible for ensuring that appropriate informed consent has been obtained.
Practices should implement consistent procedures to review consent forms before treatment commences and address any omissions identified.
A Final Word from the VDA
Consent to Treatment documentation is an essential component of clinical practice and professional risk management. As illustrated by this case, the omission of information required under an established consent protocol may have consequences extending beyond the underlying clinical complaint.
Members are encouraged to review their consent procedures and ensure that all required documentation is completed accurately before treatment commences.
A client’s signature is essential, but the scope of the treatment authorised must also be clearly documented.
Members should refer complaints or potential claims to the VDA promptly and preserve all original documentation without retrospective alteration.