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Patient consent – 8 things every doctor should know

Medical

Article

Published on 28 July 2025

Failure to properly obtain consent and document a patient's informed consent to proposed treatment is sometimes at the centre of complaints to the NSW Medical Council. In this article, we share 8 things every doctor should know when it comes to obtaining and recording their patients' consent for a course of treatment or surgery. 

Refresher – the 3 elements of informed consent

For a patient to provide informed consent, a practitioner must have given the patient enough information to have a genuine understanding of:

  1. the medical condition for which they are being treated

    2.the proposed treatment and expected outcomes, and

   3.any material risks and benefits of the proposed treatment, including alternatives and if the evidence supports one option over another.

The 8 things you should know to do

  1. Explain and document any important risks. These are risks a reasonable person in the patient’s position would likely consider important if they were told about them. A risk is also considered important if the doctor is or should know, that a particular patient, if warned of the risk, would find it significant. The risks should be specific and relevant to that patient.

  2. Take special care with pooled lists so if the consent is completed by another doctor, the practitioner responsible for the operation should still ensure informed consent is present and document/update consent if necessary.

  3. Give your patients enough time to properly consider the recommended treatment or operation. This might require giving the patient the opportunity to fully consider the proposed treatment and have them come back for a further consultation and discussion.This must clearly documented The Medical Council has found that in some complaints, the doctor notes have not been comprehensive enough to explain the decision making and details about material risks and alternatives to recommended treatment. 

  4. Ensure the patient is given sufficient time to properly consider and give their consent. Asking patients to sign their consent forms in the anaesthetic bay or changing consent forms doesn’t give a patient enough time to consider and give proper informed consent. The patient can be stressed and worried about the operation, and they need to be in a clear state of mind to consider all options and potential risks.

  5. Always discuss non-operative options with the patient. This is an important element of informed consent. It can be tempting to only discuss surgery as the appropriate pathway, but clinicians must give patients enough information about non-operative choices. Informed consent should be aided by documentation and plain language information.

  6. Make sure that if a patient requests a second opinion, this is  facilitated as part of informed consent, including other specialties and multi-disciplinary team meetings.                   

  7. Double check vulnerable patients have fully understood what they are consenting to. This especially important for patients for whom English is a second language and ensuring an interpreter is used to support patient understanding and decision-making.

  8. Be mindful that AI scribe software does not replace informed consent process but is an aid to it. AI is increasingly used by the medical profession and revolutionising medical notetaking and documentation of consent. But remember this is not set and forget. Records should be reviewed in case of  AI hallucinations. Practitioners also need to provide information to the patient about storage, security and how long AI generated records are kept. 

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