Types of Consent

Guidelines for Practice Success |Managing Professional Risks | The Consent Process

The granting of “consent” requires one person to intentionally give another person approval to do something. It’s reasonable to assume that you have implied consent to proceed with an examination and/or any procedures because the patient traveled to the practice, sat in the dental chair, answered various questions, and does not object. Beyond implied consent, the two types of consent most common within the practice of dentistry are general consent and informed consent. Both of them require a doctor/patient discussion and each should be the sole topic of discussion. Securing general consent and informed consent will involve two distinct conversations. General consent is limited to a discussion regarding the performance of certain procedures that you’re recommending for that particular patient. Obtaining general consent means that the patient has given you permission to proceed with treatment and released you from the possibility of being charged with battery. It also gives the dentist permission to perform minor restorative procedures, administer local anesthesia, and bill the patient’s insurance company. Specific informed consent is required for all other procedures. Informed consent isn’t just a document: it’s a process and discussion that educates the patient about the treatment plan you’re recommending based on his/her individual oral health status. Informed consent is required for every procedure performed other than those covered under general consent and the dentist must be the one to have that discussion with the patient. The discussion should reflect the level of risk associated with the procedure and the greater the risk, the more detailed the discussion should be. In its most basic terms, informed consent is the conversation during which the dentist gives the patient information about:
  • Any dental health problems that the dentist observed
  • The nature of any proposed treatment
  • The potential benefits and risks associated with that treatment
  • Any alternatives to the proposed treatment
  • The potential risks and benefits of alternative treatments, including not treating the condition.

The patient must have the opportunity to ask questions about the different treatment options presented. Every procedure, not just the complicated ones, requires some form of conversation. Informed consent cannot be considered legally compliant if it has not included a dentist-patient conversation. While it’s acceptable to have a clinical staff member discuss treatment options and risks, the informed consent process requires that the dentist thoroughly discusses that information with the patient. Proper implementation of informed consent is an opportunity to develop rapport with your patient resulting in enhanced dental health. The informed consent conversation also ensures that you have satisfied the ethical principle of “Patient Autonomy” in that the conversation involves the patient in treatment decisions. Consult the ADA Principles of Ethics and Code of Professional Conduct for guidance.

The dentist should secure informed consent before providing care. The requirements proving informed consent vary by state and by the type of procedure being performed. Check your state’s dental practice act or contact your state dental association for more information.

Informed consent forms should be specific to the procedure. This is especially helpful if your practice frequently provides complex treatment plans. The informed consent form can be completed after you and the patient have finished the conversation portion of the informed consent process.

Informed consent involving complex treatment should be obtained in advance of the treatment appointment to allow patients time to consider all the risks, benefits and alternatives. Informed consent obtained from patients receiving nitrous oxide or who are on certain medications effecting cognitive reasoning, high doses of benzodiazepines or opioids, for example, may be invalid.

Always confirm that the patient has signed the informed consent form before providing treatment. Your practice’s professional insurance company and/or attorney may have recommendations and resources, such as sample forms.

It’s also a good rule of thumb to make notes of your discussion with the patient directly in the patient’s record at the time of the conversation. Those notes can provide details about treatment recommendations, including the benefits, risks and alternatives. While it’s optional, some practices ask the patient to review and initial the entry to ensure it accurately captures what was discussed and to document that the doctor-patient discussion took place. At a minimum, the patient record should contain a notation indicating that the patient granted informed consent to proceed with the recommended treatment or documenting that that consent was not granted and that treatment not done. This situation is referred to as “informed refusal.” Refer to the article on Practitioner Considerations on Informed Refusal, which is included in this module, for information about handling those types of situations.

It's also important to know how to proceed in cases when a minor patient is dropped off for treatment at the practice but the parent or guardian does not stay for the appointment. Similarly, it’s important to know what to do when the patient is old enough to drive to the appointment and is not accompanied by a parent or guardian. A good rule of thumb is to obtain the parent’s consent before the appointment and confirm how the parent can be contacted during the appointment in case any complications develop. Many state laws allow the healthcare provider to proceed without parental consent if an emergency situation arises and delaying treatment could endanger the child’s health.

It’s also a good idea to consult your attorney or professional liability company for additional steps that should be undertaken when a patient refuses treatment.

This modules also includes articles on Consent for Minors/Emancipated Minors and Custody Arrangements, which provide information regarding consent for treatment provided to children or incompetent adults, since those situations require special consideration. Make every effort to maintain an impartial and objective position when dealing with parents who are unhappy about the outcome of custody arrangements. Be aware that your staff may need to request copies of legal documents, such as divorce decrees, to confirm which parent or guardian has the authority to consent to treatment and who is responsible for payment. The parent with the authority to make medical decisions for the child should sign the treatment consent form authorizing professional services and agreement for payment. In some circumstances (as where things are especially contentious between the parents), requesting a copy of the court’s order designating the parent responsible for making medical decisions for the child may be appropriate.