When is informed consent required to be documented by providers?

Informed consent is particularly relevant in situations involving higher risks and complexities, such as when prescribing opioids for chronic pain. This requirement ensures that providers discuss the risks, benefits, and alternatives of the treatment with the patient, who must then acknowledge their understanding and agreement. The need for informed consent in this context is mandated to protect both the patient and the provider, given the potential for misuse, addiction, and other significant side effects associated with long-term opioid therapy.

In contrast, less risky or routine treatments may not necessitate the same level of documentation for informed consent. For instance, first visits may involve some discussion of treatment plans, but not every first visit will require formal informed consent as extensive as that needed for opioid prescriptions. Routine check-ups typically do not involve significant treatment decisions that would necessitate documented informed consent, nor is there a requirement for such consent at every prescription refill, as these may not represent substantial changes or risks to the patient's treatment.