Theme notesConsent & safety
Theme notesConsent & safety
Consent, records & a safe practice
Make reasoning visible to the family, the record, and the team. Consent is a conversation, documentation preserves that conversation, and safety is a repeatable process.
Remember
Discuss → check understanding → document → verify → learn.
Key points
Verify the legally authorized decision maker. Explain diagnosis, proposed care, benefits, material risks, alternatives, and no treatment; seek the child’s assent when appropriate.
Consent (PDF opens in a new tab)Update health information at each visit. Record findings, diagnosis, reasoning, consent/refusal, care, medications, complications, instructions, and follow-up; protect access and transfer.
Recordkeeping (PDF opens in a new tab)Use two patient identifiers and a team time-out before invasive care. Confirm procedure and tooth/site, and assess fire risk from ignition, fuel, and oxidizer.
Patient safety (PDF opens in a new tab)Answer aloud
The consent form is signed. Is that enough?
No. Confirm understanding and voluntary permission through discussion; use a qualified interpreter when needed. For a minor without independent consent authority, obtain parental or authorized-guardian permission and seek assent when developmentally appropriate. Revisit consent when the proposed procedure or risks change.
Consent (PDF opens in a new tab)You discover an error in a clinical note. What do you do?
Keep the original legible.
- On paper, draw one line through the error and add initials/signature and date.
- In electronic records, add a separate correcting entry.
Follow applicable access and retention requirements.
Recordkeeping (PDF opens in a new tab)A near miss occurs. How does the team respond?
Report and examine contributing causes in a fair, learning-focused culture, then improve the workflow. Include equipment, medication, communication, and emergency-readiness checks.
Patient safety (PDF opens in a new tab)Compare who can consent
Scroll across to view all columns
| Person | Consent status | Verify before treating |
|---|---|---|
| Parent with legal rights | Generally may consent unless a court order provides otherwise | Scope of authority for adoptive parents, guardians, and foster-care arrangements |
| Grandparent, stepparent, babysitter, or noncustodial parent | Not automatically authorized | Legal authority (a court order for a guardian), or reach the parent |
| Emancipated minor | Independent consent within the permitted scope | Legally recognized emancipation under applicable law |
| Adult with intellectual disability | Assess capacity; the diagnosis alone does not establish incapacity | Supported decision-making or an authorized guardian, per state law |
| Child | Seek assent when developmentally appropriate; parental/authorized-guardian permission needed unless independent consent is permitted by law | Document the discussion and use a professional interpreter when needed |
Quick decisions
What must informed consent for pediatric dental care include?
legal decision maker; diagnosis, care, benefits, risks, alternatives, no treatment; assent when developmentally appropriate
What checks should you complete before an invasive dental procedure?
two identifiers, time-out, tooth/site, fire risk (ignition, fuel, oxidizer)
Decision pathways
Sources
- Informed Consent, 2023
- Recordkeeping, 2026
- Policy on Patient Safety, 2025