Should you document that you informed the patient of procedural problems if they occur?

• A. True
• B. False
• C. Only if asked by patient
• D. Not necessary

Answer: (A)

Documenting that you informed the patient about any procedural problems is essential practice. When a complication or deviation occurs, you’re obligated to communicate what happened, what it might mean for the patient, and how you plan to proceed. Recording this discussion protects patient autonomy, ensures the patient understands the situation, and provides a clear record of what was disclosed and agreed upon. The note should include what happened, the risks discussed, any questions the patient had, and the chosen next steps or changes to the plan, along with date, time, and who conveyed the information. This documentation supports continuity of care, quality assurance, and legal protection, and it’s not contingent on the patient asking about it.