Guidelines for Practice
Consent For Care In Dentistry
In order to practise in a professionally responsible manner, dentists must assist patients to make well informed decisions about treatment procedures.
This discussion paper deals with some essential principles of this process.
The Fundamentals of Consent for Treatment in Dental Practice
By the action of consulting a dentist a patient's consent for examination is implied.
The term ‘consent‘ is defined thus : When two or more persons agree upon the same thing in the same sense they are said to consent as per the definition of ‘consent ‘ given in section 13 of Indian Contract Act, 1872.
Who can given consent:
For the purpose of clinical examination diagnosis and treatment consent can be given by any person who is conscious, mentally sound and is of and above twelve years of age as provided under sections 88 and 90 of the Indian Penal Code, 1860.
Dentists are reminded that consent is taken under section 13 of the Indian Contract Act, 1872. This Act, however also provides under Section 11 that only those persons who are of and above 18 years of age are competent to enter into a contract. Since dentist-patient relationship amounts to entering into a contract, it is advisable that consent should be obtained,specially written consent, from parents / guardian of a patient who is below 18 years so that validity of the contract is not challengeable.
Strictly speaking, however, no further service should be provided without the express consent of the patient, although with regular patients who only require relatively minor and familiar maintenance procedures, implied consent would usually pertain.
Oral consent is sufficient for most dental treatments; but for procedures such as general anaesthesia and major oral and maxillofacial surgery written consent is needed and this consent should include contingency consent to cover unforeseen eventualities.
Mere agreement by a patient does not fully satisfy the requirement of consent. For this to be valid, some information about the proposed procedure(s) must be provided and the patient must understand what it is to which he or she is consenting.
The Nature of Consent for Treatment
Essentially, an informed decision about treatment has four elements:
Sufficient relevant and accurate information on which to base a decision.
This might include explanations of:
The proposed treatment plan (indicating to what extent it depends upon established versus relatively new or controversial procedures) and its cost.
Likely prognosis, outcomes and benefits.
Possible complications, side-effects and material risks inherent in the treatment.
Possible alternative treatments and cost options.
Likely consequences of no treatment.
Any other aspects requested by the patient.
Comprehension of the information.
A clinician can contribute to this by:
Use of simple language.
Allowing adequate time for questions.
Taking into account such factors as cultural difference and language comprehension.
Legal competence to make personal decisions.
Relevant considerations are:
As a general rule, consent for treatment of minors, the intellectually disabled or others not considered legally competent to make decisions on their own behalf, should be obtained from a parent, guardian or attorney (as appropriate) who must be provided with the same amount of information as would be required for adult consent.
Substitute decision-making processes are also needed for adults incapable of providing consent.
In an emergency, when immediate intervention is necessary to preserve life or prevent serious harm, it may not be possible to provide information.
Absence of coercion.
It is important that:
Consent is voluntarily given.
No misleading information is offered.
Ample time is allowed for decision.
The patient's option to refuse or withdraw at any stage from treatment is understood, even though such treatment is aimed to be in the best interests of the patient and failure to have it may be harmful.
Possible consequences of not obtaining consent for treatment
In most of the cases filed against the doctors it is alleged that no consent was obtained. Obtaining of a consent will thus be a cornerstone of protection against litigation - unless the failure to obtain consent is justified by necessity: for example, in an emergency.
Consent is not valid when given under fear, fraud or misrepresentation of facts, or by a person who is ignorant of the implications of the consent, or who is under 12 years of age is invalid ( Sec. 90 I.P.C.). The most applicable sanction for failure to disclose this sort of information lies in the tort of negligence. It is accepted that a practitioner's general duty to act reasonably includes a duty to provide adequate information, particularly in relation to risks or hazards.
If something goes wrong then the practitioner may be exposed to liability for damages in negligence. A negligent act is usually found or alleged to have occurred in the procedure itself. However, a failure to provide information about the procedure and associated risks may also amount to negligence.
For action in negligence on the latter score to succeed, two points must be established:
(a)that failure to disclose the information was unreasonable; and
(b)that this failure was a cause of harm to the patient.
The measure of reasonableness in relation to information-giving is akin to the standard of care required in relation to diagnosis and treatment, viz. that of an 'ordinary careful and competent practitioner of the class to which the practitioner belongs'.
To satisfy the second element (causation), the patient must establish both that he or she would not have consented to the treatment had proper disclosure been made and that injury was suffered due to the treatment.
At present it is not easy for the plaintiff/patient to establish any, let alone all of these things, especially causation. Actions in negligence are often unsuccessful. The mere fact of treatment without consent will not be regarded as compensatible injury. However, this may undergo change as the law in medical negligence evolves further, particularly in the areas of:
(i)determining the weight that is to be accorded evidence derived from standard practice; and
(ii)assessing whether risk was material, that is, whether it would have influenced a reasonable person in the position of the patient in deciding whether to accept the procedure in question.
Consent for Care in Dentistry
Quality of communication It is not a main purpose of this paper to engage in much discussion on the separate subject of communication in dental practice.
Nevertheless, in the present context it must be kept in mind that good communication lies at the heart of successful dentist/patient relationships, whilst poor communication is likely to engender apprehension, dissatisfaction, suspicion and possible litigation. Communication skill has many aspects.
Practitioners may require improved ability in listening and feedback techniques, avoidance of technical language, or understanding of negotiation, decision-making, behavioural processes and the needs of minority groups.
The effect of time spent on communication is less dependent on its quantity than its quality. Thus commitment to providing patients with ample basis for consent will not necessarily increase the cost of treatment, particularly if improvements in treatment efficiency or reductions in stress and anxiety for the patient follow better communication.
In explaining the nature of proposed treatment, communication can effectively be extended by use of diagrams, suitable pamphlets and other literature, photographs, videos and models. The cost of a proposed treatment plan is always an important aspect to be communicated.
Determining reasonable disclosure Whilst the extent of information which should be given to patients will depend on the circumstances of each case, the courts have at least provided some guidance. Matters are material if they 'might influence the decisions of a reasonable person in the situation of the patient'. If, for example, a risk involves potential harm or injury so slight, or so unlikely to occur, that no reasonable person would be influenced by it, then that risk need not be discussed.
From a health provider perspective, however, it would usually be preferable for disclosure to be based not so much upon an hypothetical 'reasonable person' as on the circumstances and needs of the particular patient in question.
Relevant factors, especially in relation to risk, might include: The nature of treatment.
More drastic treatment requires more information. There is clearly a difference between orthognathic surgery and plaque removal. Most procedures carried out in general practice would be considered minor.
However, an extensive treatment plan composed of numerous minor items will require elaboration, as will more costly or controversial items.
The magnitude and/or likelihood of possible harm.
Information about the possibility of serious harm should normally be given even if the chance of it occurring is slight. Similarly, information should generally be given if the potential harm is relatively slight but the risk of it occurring is great.
Typical risks in general dentistry which may need to be mentioned include the possibility of nerve damage in oral surgery procedures, perforation or instrument breakage in endodontics, and crown and bridge failures. It is probably not necessary to discuss risks that are inherent in any operation, such as post-operative infection.
The personality, temperament and attitude of the patient.
More information must be given to those keen to have it for more than just reassurance, especially in response to specific questions. On the other hand, it is not necessary to force information on a patient who is prepared to leave all decisions to the service provider. On occasions, albeit rarely in dentistry, it would be considered justifiable not to volunteer certain information if there are reasonable grounds for believing that the patient's health or welfare might be seriously harmed by being given the information.
The patient's level of understanding.
Without it being necessary to cross-examine a patient to ascertain understanding, information-giving should be influenced by some appraisal of the patient's intelligence and apparent understanding, and made in the light of the simplicity or complexity of the proposed treatment. Seeking some feedback from the patient may give an indication of his/her comprehension.
Permanent records In all situations it is necessary to keep careful, clear records. Disclosure of information and subsequent oral consent (which suffices for the vast majority of dental procedures) should be listed in the clinical notes.
For major treatment, either in terms of invasiveness or expense, written consent forms acknowledging that the nature, implications and risks of the proposed procedure have been explained may provide substantial, although still not entirely conclusive, evidence that information was given and consent granted. Whenever in doubt about whether a procedure is major or minor, written consent should be obtained. An appropriate alternative may be to have adequately written records of the information given, shown to and initialled by the patient.
Potential controversies Dentists must take care always to mention any proposed use of treatments which, although considered standard, safe and minor procedures by the dental profession, might be regarded with some doubt by certain patients (for example, X-rays or amalgam fillings), so that these patients have the opportunity to request further information or decline such treatment modalities.
Procedures which have yet to receive general acceptance as standard or desirable practices, or which do not accord with mainstream dental opinion, necessitate the precaution in every case of ensuring that "fully informed" consent is forthcoming.
Less tangible items of treatment Genuine service should be free from any suspicion of overservicing. Consent for relatively minor procedures which might not be very apparent after completion, such as occlusal adjustment, recontouring of existing restorations or fissure sealants, especially if numerous, will often require fuller justification than more obvious items.
Situations in which authority is not clear If a practitioner cannot be certain that consent is valid: for example, where there is conflict between parent and child, or where a child or other legally incompetent person is under the control of a person not normally authorised to give consent; then it would be unwise to proceed with treatment (except in the case of an emergency) until the situation is clarified.
Treatment alternatives Where alternative treatments have been expounded, a dentist should accept the patient's preferred option within reason. For instance, few dentists would have problems about providing a partial denture rather than a bridge or a complex amalgam rather than a full crown on the basis of the patient's informed decision. But it is usually better to decline giving a treatment of the patient's choice which, although included among discussed options, has been recommended against or declared undesirable: for example, the provision of an immediate full denture rather than a recommended course of relatively simple conservative work. In the event of problems, it is preferable not to have acted contrary to one's own recommendation.
If any part of an accepted treatment plan is to be delivered by someone other than the dentist presenting it, such as another dentist or auxiliary within the practice, then the patient must be made aware of this in advance.
The subject of consent is constantly under review by the legislature and Courts. These Guidelines have attempted to express views consistent with the Law as at the date of their publication.
Emergencies In Dental Practice
Introduction
Dentists and their staff should be prepared for emergency situations which will occur at any time in their practices. These emergencies range from the minor such as the common faint [vaso- vagal syndrome] and hyperventilation, to the life- threatening such as cardiac arrest or anaphylaxis.
If it is possible to over-prepare, however and it is
The aim of this Code to be as Simple as Practicable
since over preparation without appropriate experience will be counterproductive and even dangerous [e.g. excessive drugs and equipment.]
Five Steaps in the Preparation for Emergencies.
Step 1.Medical History.
Step 2.Assessment of patient/Recognition of cause of emergency
Step 3.Resuscitation - knowledge, training and practice.
Step 4. Emergency Drugs and Devices.
Step 5.Calling for Medical Assistance.
Step 1.Medical History.
This aspect of practice is constantly covered and therefore, will not be laboured but should include:-
- Date of birth.
- Physician's name, telephone number and address.
- Past and present serious illnesses.
Prompts:
Heart disease
[Ischaemic heart disease/congestive heart failure]
Blood pressure
Stroke
Rheumatic heart disease
Diabetes
Asthma
- Blood transfusion history Prompt: If positive: Are you being treated by a doctor at present?
- Allergies to drugs, medicines, antiseptics.
Prompts: Penicillin
Local anaesthetic
Antiseptics
Latex.
Present Medication.
Prompt: What medicine, pills. tablets or drugs are you taking or have you taken recently [in the last six months]
Where there is any doubt regarding the patient's medical status, the dentist should consult the patient's medical practitioner.
STEP 2. Assessment of Patient.
The following conditions are recognised as the predominant causes of medical emergencies in dental surgeries.
The first five are stress related. ie. initiated or aggravated by emotional stress and stress minimisation techniques can assist in the prevention of such conditions.
The conditions will exhibit a range of clinical features and the dentist should be vigilant regarding the patient's medical history and the circumstances which may have provoked the condition.
CONDITION
CLINICAL FEATURES
TREATMENT/ RESPONSE
- Vasovagal syncope [fainting]
approximately 40%.
Faintness, weakness, pallor, sweaty skin,
lowered pulse rate, hypotension.
Lie horizontally, elevate feet, oxygen, monitor vital signs.
- Hyperventilation
approx.30% [frequently
confused with syncope].
Dyspnoea, rapid breathing, faintness,
paraesthesia of extremities, palpitations.
Encourage slower breathing, rebreath expired air with a paper bag.
- Asthma
[Medical History]
Dyspnoea, cyanosis, audible wheezing, cyanosis.
Reassure, use up to 4 metered doses of aerosol bronchodilator.
- Angina Pectoris
[Medical History]
Moderate to crushing central chest pain, radiating to left arm, neck or mandible.
Stop treatment, place one glyceryl trinitrate tablet 0.6 mg under tongue or spray under tongue.
Repeat dose in 5 minutes after first checking BP and again after another 5 minutes if pain persists.
If no improvement after 15 minutes, treat as acute myocardial infarction.
- Acute myocardial infarction.
[Medical History. eg. angina pectoris, acute myocardial infarction, hypertension, diabetes.]
Chest pain similar to angina but unrelieved by up to 3 glyceryl trinitrate tablets over 10 minutes. Suspect in anginal patient who says pain is much worse than usual, or if this is first ever episode of chest pain.
Monitor vital signs. 100%
oxygen. Dissolved aspirin tablet and one glyceryl trinitrate dose stat and one repeat in 5 minutes after check of BP.
- Cardiac arrest.
[Medical history especially angina and acute myocardial infarction.]
Sudden unconsciousness, no breathing, no pulse.
[Irreversible brain damage in 3-5 minutes] Initiate cardio pulmonary resuscitation, early defibrillation, oxygen.
- Epilepsy [Grand Mal] [Inquire as to control of condition, medication, last episode.]
Sudden unconsciousness, temporary aspnoea and cyanosis in tonic phase, involuntary movement of limbs in clonic phase.
Place in lateral position, protect from injury, monitor vital signs, oxygen, medical assistance.
- Toxic effects from LA [rare].
- Adrenaline toxicity - restlessness, throbbing heIDAche, pallor, rapid full pulse, palpitations.
- LA base toxicity - first CNS stimulation then depression with convulsions.
Basically supportive - effects should terminate rapidly.
- Hypoglycaemia [History of insulin dependent diabetes.]
Slurred speech, altered behaviour, sweating, rapid pulse, apprehension, then loss of consciousness.
Give orange juice, glucose drink or sugar lumps at first sign which will rapidly terminate event ie. loss of consciousness should never occur. If loss of consciousness occurs, will need parenteral therapy [glucose or glucagon.]
- Acute airway obstruction [choking].
Sudden aspnoea or dyspnoea cyanosis, violent coughing spasms, inability to catch breath.
Try to remove cause - 5 back blows with patient leaning forward. If unable to remove, administer oxygen, arrange transfer to hospital for bronchoscopy.
- Severe Allergic reaction. [Anaphylaxis].
- History of allergies.
Asthma like symptoms. [sneezing and dyspnoea] circulatory collapse, cardiac arrest, following drug administration.
Always check that respiratory distress not due to other causes.
Adrenalin 1:1000 IM [1/2 ml] as injection or epipen.
May need to repeat dose after 5 minutes.
100% oxygen. CPR if cardiac arrest occurs.
COLLAPSE
Check response, shake and shout
STEP 3. Resuscitation - Knowledge, Training and Practice.
Further annual refamiliarization courses are recommended to main competence in basic life support [BLS].
All dentists should be competent in BLS resuscitation. That is, they should be able to assess breathing and circulation and to carry out effective expired air resuscitation [EAR] and Cardio- pulmonary resuscitation [CPR] if required. They should also encourage their staff to attend resuscitation courses and run practice drills. A wall poster can assist in retention of learnt techniques.
When an emergency is immediately life threatening such as complete laryngeal obstruction, cardiac arrest associated with acute myocardial infarction or bronchospasm associated with anaphylaxis, there is no time for delay and an immediate diagnosis must be made and definitive treatment initiated.
IDA recommends the DRABC basic sequential steps for all emergency situations. These steps are to ensure an adequate delivery of oxygenated blood to the brain prior to the delivery of definitive care –
D = Check for danger.
R = Check if the patient is responding.
A = Check the airway for obstruction.
B = Assess breathing.
C = Assess circulation.
Flow Chart for ABC of Resusctation.
CONSCIOUS
Make comfortable
Observe. Airway
Breathing
Circulation
UNCONSCIOUS
Turn on side
Face slightly downward
Clear airway
Head tilt
Jaw support/jaw thrust
Check for breathing
Observe. Airway
Breathing
Circulation
5 full breaths
[10 seconds]
EAR
Check carotid pulse
Check pulse and breathing
after 1 minute and then at
least every 2 minutes.
PULSE ABSENT
CPR [EAR and ECC]
Check pulse and breathing
after 1 minute and then at
least every 2 minutes
Expired air resuscitation (EAR)
External cardiac compression (ECC)
Cardiopulmonary resuscitation (CPR) ie. EAR and ECC
STEP 4. Emergency Drugs and Devices.
The administration of emergency drugs is always secondary to providing life support during an emergency.
There are no mandated lists of emergency drugs and equipment kits except in the practices that undertake intramuscular or intravenous sedation or general anaesthesia. Dentists who undertake the administration of oral conscious sedation on children or adults should have adequate training to deal with any side effects. It is recommended, though not mandated, that a general practice retains on its premises the following :
! Oxygen
! Oral glucose
! Adrenaline 1:1000
! Clyecryl trinitrate spray or tablets.
Oxygen.
All surgeries should have an oxygen source which is easily transported to the patient. The simplest and safest way of administering oxygen to a non-breathing patient is via a pocket mask with a nozzle to which a low pressure oxygen line is connected. At a flow rate of 10L/minute this provides about 50% oxygen in the ventilated air. The mask should have an adjustable head strap. Oxygen powered resuscitators are considered part of advanced life support [ALS] because of the risk of gaseous distension of the stomach resulting in regurgitation, therefore, are not recommended. It is now considered that these resuscitators require two operators.
Oral Glucose.
For insulin dependant patients who are exhibiting signs of hypoglycaemia, administration of orange juice, glucose or sucrose drinks or sweets in small amounts [50-100 ml] every five minutes, will rapidlyraise the blood sugar level and reverse the situation.
Adrenalin 1:1000.
When a severe anaphylactic allergic response is diagnosed, an injection of 0.3 - 0.5 mg
[0.3 ml - 0.5 ml of 1:1000 solution] on to the tongue, floor of the mouth or other muscle is required. Adrenaline is available as a 1 ml 1:1000 solution in a pre-loaded syringe. Two such pre- loaded syringes should be kept, as the injection may need to be repeated. Pressure adrenaline kits [epipens] are available in adult and child doses.
Glyceryl Trinitrate Tablets or Spray.
Patients with a history of angina usually have their tablets with them and administer their usual dose sublingually. However, it is recommended that the dentist's emergency kit contain glyceryl trinitrate spray [which has a much longer shelf life than tablets] in case the patient does not have his/her glyceryl trinitrate [GTN] tablets.
STEP 5. Medical Assistance.
It is appropriate for a dentist to make established links with his nearest medical practitioner or facility. Therefore, these should be displayed in a prominent place. Other than administering oxygen, it must be stressed that no drugs should be administered if a dentist is not adequately trained and confident of the diagnosis.
Patient Information And Records
Why Make Records?
A record of each encounter with a patient is an essential part of the practice of dentistry, which improves diagnosis, treatment planning, case management and fees control.
Accurate records assist efficient and complete delivery of care in the event of another clinician assuming that patient's treatment. Patient records may be used in a forensic role for patient identification.
Patient records form the basis for retrieval of treatment details in the case of a dispute or the requirement to provide evidence. It is desirable that such details provide an adequate contemporaneous record that obviates the need for any later, and possibly questionable, assumptions that a dentist’s ‘usual practices’ were followed in a specific case.
Personal details [besides health information] are needed for satisfactory business management of a patient. This record should include the name of the person or entity responsible for payment for the treatment.
Features which make health information special include:
Confidentiality of collection. Health information is collected in a situation of confidence and trust in the context of a dentist/patient relationship and may be of a sensitive nature.
Sensitivity of information. Some health information is highly sensitive and can include details about an individual's body, lifestyle and practices which are particularly intimate or which may, if improperly disclosed, be misused. Duration of retention. Health information may be required long after it has ceased to be needed for the original episode of care and treatment.
What Constitutes Records?
Notes made by clinicians and staff.
Completed written medical history.
Consent documents.
Copies of correspondence about the patient.
Radiographs, tracings, measurement.
Diagnostic casts.
Special test findings.
Photographs.
Records of financial transactions.
Standards For Record Keeping.
Records must comply with statutory requirements and should include the following information about the individual:
Name, birth date, address and telephone [facsimile] contacts of the patient.
Gender of the patient.
If the patient is under 12 years of age, the name and address of a parent or guardian.
An adequate medical history which is updated regularly.
The date of every visit and appointment made which the patient failed to attend.
Records should also include where appropriate :
A description of the presenting complaint, relevant history, clinical findings, diagnosis, treatment options and treatment plan agreed to.
Advice given to the patient * on:
Treatment options
Pre and post operative instructions. Likely outcomes.
- * References hereafter to ‘patients’ should be read as ‘patients and where applicable, their custodial parent(s) or guardian (s) or duly authorised person.'
Any treatment undertaken. Notes should include detail about the material used, variation from your usual technique and comments on the procedure. The detail should reflect the complexity or seriousness of potential sequelae.
Any treatment advice that the patient was unwilling to accept.
Drugs prescribed [quantity, dose, instructions.] Drugs administered [dose]
Consents obtained for treatment .
Unusual sequel to treatment reported by the patient.
Estimates or quotations for fees.
Relevant comments by patients on concerns over offered treatments.
Any comments or complaints by patients about treatment provided.
Staff make annotations following telephone conversations etc.
All comments should be couched in objective, unemotional language.
It is desirable that the treating dentist does not delegate responsibility for the accuracy of medical and dental information to another person.
Records should be legible and abbreviations standard ones. They should be readily understood by any third party [particularly another dentist] accessing the file.
Where corrections are necessary, liquid paper products or erasable pens should not be used. Corrections should be undertaken by the person striking out the incorrect words and rewriting the correct words. If the document is being rewritten the original document should be kept as a reference.
Computer Records
The principles applying to hand written records also apply to computer records.
Computer records should be time logged and, if codes are used, they should be readily convertible to conventional language.
Other desirable features pertaining to computer records are : A dental practitioner’s records must show who made each entry and when it was made;
it must not be possible for entries to be changed without trace, i.e. there must be an audit trail; there should be security procedures such as access being available only by password; there must be a standard procedure for entering treatment record data that is recorded in an office manual or memorandum to the practitioner’s staff; there must be adequate computer back up systems in place.
Storage and Security of Records.
It is the responsibility of the dentist and staff to keep in confidence information derived from a patient. Information should only be divulged from a patient in accordance with relevant legislation.
Appropriate arrangements should be made for the adequate physical security of patient records.
Retention of Records.
The retention of records must comply with statutory requirements but, as a general rule, with the possible exemption of diagnostic casts, all records should be kept for at least seven years after the date of the final entry.
Records relating to the treatment of minors should be retained for at least seven years after the minor has attained majority.
If records are released for whatever reason, dental practitioners should obtain an acknowledgment receipt and also retain copies for their own records. In the case of radiographs, if it is a contentious issue a copy should be kept.
It is a reasonable alternative that diagnostic casts be given to the patient and regarded as a patient held record.
Access TO Records.
Patients need access to the information in dental records for a variety of reasons. Some move to a new town or suburb and need to consult a new dentist. Others may have compensation cases lodged with the courts, where their medical/dental condition and treatment are central issues. Some patients simply want to understand what is wrong with them and to fully understand the treatment they have had or intend to have.
It is preferable that the information should be provided in a report, and not simply by sending on a copy [never an original] of the records. A report written for the express purpose of the request may be far more helpful than the records themselves.
Records remain the property of the practitioner. In some jurisdictions, regulations entitle patients to view or obtain copies of their records.
In some jurisdictions, regulations entitle patients to obtain copies of any radiographs and records, or a report of their treatment, at their own expense.
Consent Records.
Implied consent is by far the most common variety of consent in dentistry. The fact that a patient comes to a dentist for an ailment implies that he is agreeable to dental examination in the general sense. This, however, does not imply consent to procedures more complex that inspection,palpation, percussion and routine work. For more complicated diagnostic procedures express written consent should be obtained.
In order to practice in a legally defensible and professionally responsible manner, a practitioner must assist patients to make well informed decisions about treatment procedures.
! By the action of consulting a dentist, consent for examination is implied.
! Implied consent would usually pertain for minor and familiar procedures.
! For more complex procedures a more formal consent [which may be verbal or written] is required.
! Mere agreement by a patient does not fully satisfy the requirement of consent.
For this to be valid, some information about the proposed procedure must be provided and the patient must understand what it is he or she is consenting to.
In all situations it is necessary to keep careful, clear records. Disclosure of information and subsequent oral consent [which suffices for the vast majority of dental procedures] should be listed in the clinical notes. For major treatment, either in terms of invasiveness or expense, written consent forms acknowledging that the nature, implications and risks of the proposed procedure have been explained, may provide substantial evidence that the information was given and consent granted.