In judging whether disclosure is adequate, a physician can use the following two standards that the courts use as a guide:

46.3.3.1 Reasonable Doctor Standard/ Professional Standard

This standard promotes that a physician reveal the same information that other physicians would disclose in the same or similar circumstances [20].

46.3.3.2 Reasonable Patient Standard/Legal Standard

This standard holds that a physician reveal the information that a reasonable person would consider material in deciding whether to undergo or forego treatment [21].

The standard used by the courts varies according to the laws of each state. Dermatologists should acquaint themselves with the standard used in their jurisdiction to ensure that their disclosure is both medically and legally adequate.

Both informed consent and refusal take on important roles in the treatment of skin cancer because many different treatment options exist. It is important to discuss with patients their diagnosis, its progression if left untreated, the recommended treatment along with potential risks and benefits, and viable alternatives including their respective risks and benefits [22]. Viable alternatives is an important concept in that a physician does not need to disclose a diagnostic or treatment option he or she does not believe is viable. Yet, physicians should be careful to make sure that they have solid reasoning when they decide an option is not viable.

The best way for physicians to avoid problems with informed consent and informed refusal issues is to communicate fully and document as well as possible. This process should not be rushed, and patients should be given the opportunity to ask questions and express any concerns. In addition, it is important for patients to verbalize understanding of the procedure or the possible consequences of refusal of treatment.

Summary: Medical Records

•Medical records are extremely important when a medicolegal situation arises.

•Medical records should be complete and tailored to the individual patient’s case.

•A discussion of risks, benefits, and alternatives should be documented in the medical record prior to any surgical procedure.

46.4Medical Records

It is difficult to overemphasize the importance of the medical record. After all, the medical record is the central repository of all patient-related medical information and is vital for planning, delivering, and chronicling medical care. In the event of a legal situation, the contents of this record may often be the only available credible evidence [23]. Thus, it is of utmost importance to both patient care and malpractice defense that a physician takes care to insure the accuracy and completeness of the medical record.

When contemplating the types of information that should be recorded in a medical record, a physician should keep in mind that most objective patient information, such as positive or negative findings which are essential to care or are customarily recorded, should be included [24]. Discussions with patients or relevant third parties, whether conducted in or out of the office, should also be documented whenever possible [24]. Additionally, the entire informed consent process should be recorded, including signed forms, treatment plans, and warnings given to patients [24]. Finally, any adverse events or complications should be included [24].

The following is a checklist for keeping medical records:

•Avoid disapproving comments or statements that are self-serving. Document from a patient care perspective.

•Record should be complete and, preferably, concise.

•Records should be consistent. Avoid lengthy chart entries as methods of risk management if the typical note for such an encounter is brief. This type of deviation in record keeping can invite unwanted suspicion.

•Do not alter medical records, unless it is essential for patient care. If a correction to the record is necessary, it is preferable to line out the item and initial and date the correction. It is also acceptable to enter a new note or addendum referencing the correction or addition. Avoid attempts to hide, make illegible, or delete the initial entry without indicating that you have done so.