What is the best practice for documenting informed consent in a dental practice?

• A. Only obtain signature
• B. Record consent verbally with no signature
• C. Document patient understanding of risks, benefits, and alternatives; obtain signature; update if plans change.
• D. File consent in a separate department

Answer: (C)

Documenting informed consent effectively means capturing that the patient truly understands what will be done, the risks and benefits, and the alternatives, and recording that understanding in the chart with a signed acknowledgment. This comprehensive approach protects patient autonomy and provides a clear, defensible record that the patient agreed to the plan after being informed. It also requires updating the consent whenever the treatment plan changes, so the record reflects the current plan and continued agreement.

Relying on a signature alone misses whether the patient truly understood the information and may not document key details like risks discussed or alternatives considered. Verbal consent without a written record lacks evidence of what was communicated. Filing consent in a separate department can create barriers to timely access and accountability. In practice, you want a clear discussion of risks, benefits, and alternatives, a signed or electronically signed consent form, and a note in the chart if plans change that leads to a new consent.