08 August 2024

As the number of complaints, claims and regulatory referrals in this field of medicine continues to rise, we talk to practitioners frequently about the value in strengthening their practice in a number of key areas.

Here, we look at the importance of having robust processes in respect of consent, record-keeping and patient selection.  These topics often form the basis of a claim or referral, so it’s worth spending time to ensure that your practice is up to speed.

Consent

We often see cases where the patient will claim that they didn’t understand the risks associated with the treatment and wouldn’t have gone ahead had they been fully informed. So, how can practitioners avoid this scenario?  Here are our top tips:

• Advise the patient of all material risks, and have in mind that some risks that wouldn’t ordinarily be material might have particular significance to certain patients.  It is important to tailor the consent discussion to the patient in front of you.

• Advise of any alternative treatments that might be suitable for the patient, and remember that the best option for the patient might be to have no treatment at all.

• Make sure you are satisfied that the patient has understood the nature of the treatment and the associated risks and benefits.  In practical terms, we suggest to practitioners that they have the consent discussion with the patient and then ask the patient to tell them what they have understood from the discussion.  This can be helpful in identifying any miscommunication at the outset. 

• It is often helpful to have a “cooling off” period between the consent discussion and the start of treatment.  This allows the patient time to consider the options, risks and benefits, and come back to the practitioner with any follow-up questions.

Record Keeping

It is not necessary to record every detail of your discussion with the patient and every detail of the treatment.  This is simply not practical.  Instead, focus on ensuring that your records are clear, concise and contemporaneous. 

Here are our top tips to avoid some of the common pitfalls:

• Record the key elements of the consent discussion and any treatment.

• If your computer software generates standardised notes or pro formas, make sure those notes are directly relevant in the particular circumstances and tailor them if required.

• Your notes can be supplemented with additional documentation such as patient information leaflets and signed consent forms. Try to avoid medical jargon in documentation that needs to be read and understood by patients.

• If it is your practice to draw diagrams for patients (which is common in aesthetic medicine) include your drawings in the patient records.

Patient selection

During your initial consultation with a patient, it is important to get an understanding of their motivation for treatment and their expectations.  This is a good opportunity to determine whether the patient’s expectations are aligned with your own.  If they are not, you may wish to decline treating the patient.  Whilst practitioners are well aware that they can turn patients away, we often find that the genuine desire to help patients can influence practitioners to proceed in circumstances where the best option might have been to decline the request for treatment.

Summary

These key topics are well known to aesthetic practitioners, but re-visiting them with a view to strengthening your practice and systems can help avoid claims and referrals, or ensure that you are well placed to respond to them.

Cara Docherty is a Senior Associates in BTO’s Professional Discipline and Clinical Defence team.  If you would like to have an informal discussion, please get in touch.

Cara Docherty, Senior Associate: cdo@bto.co.uk / 0141 221 8012