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Psychiatrists' documentation of informed consent

D Schachter¹, I Kleinman

¹Department of Psychiatry and Public Health Sciences, University of Toronto, Clarke Division, Ontario.

Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie

|December 30, 1998

Summary

Psychiatrists often do not document informed consent for antipsychotic medications, with chart reviews showing documentation in only 23% of cases. Improved documentation is crucial as it serves as the sole record of the consent process.

Keywords:

Empirical Approach Mental Health Therapies Professional Patient Relationship

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Area of Science:

Psychiatry
Medical Ethics
Health Informatics

Background:

Informed consent is a cornerstone of ethical medical practice, particularly for treatments involving significant risks and benefits.
Antipsychotic medications are widely used but carry potential side effects, necessitating thorough patient understanding and agreement.
The documentation of the informed consent process is vital for legal and ethical accountability.

Purpose of the Study:

To assess current psychiatrist attitudes and behaviors regarding informed consent for antipsychotic medication.
To evaluate the extent to which the informed consent process for antipsychotic medication is documented in patient records.

Main Methods:

A survey of 30 psychiatrists from teaching and non-teaching hospitals was conducted.
Participants completed questionnaires on their attitudes and practices related to informed consent documentation.
A retrospective review of patient charts was performed to verify documentation rates.

Main Results:

Psychiatrists reported inconsistent documentation of the informed consent process.
Chart reviews indicated that, on average, only 23% of patient charts contained documentation of informed consent.
Affiliation with a teaching hospital and frequent reading of medical journals correlated with higher documentation rates.

Conclusions:

Routine documentation of the informed consent process for antipsychotic medication is not consistently practiced by psychiatrists.
Enhanced attention to documenting informed consent is recommended, as these records are essential for accountability.
The findings highlight a gap in clinical practice regarding the documentation of patient consent for antipsychotic treatments.