How a dentist records the consent process is a matter for the judgement of the individual clinician. It should be borne in mind however that very few clinical records (if any!) contain too much information on the process by which how consent was obtained.
If there is little or no evidence of a consent process then this can present difficulties if a legal claim arises.
To avoid such problems arising, the dentist should aim to document all of the information relating to the discussions and advice on treatment options within the patient record.
Although there may be practical constraints for clinicians working in HSE clinics, it is recognised in the general practice setting that providing a “treatment plan” letter and asking the patient to sign and return one copy to the practice to be retained in the records can be a very useful way to both inform the patient and also to record that a course of treatment has been agreed. Clinicians who work in the HSE will of course need to adhere to the standards of their own local service in terms of information provided to patients and their parents/carers. It is however important to recognise the need to ensure that there is clear evidence in the clinical records that a consent process has been followed and that a clear understanding of the treatment proposed is in place before this proceeds.
Some helpful tips on this topic are contained in the advice booklet produced by Dental Protection entitled ‘Consent to Dental Treatment’ which is available to download from our website