As a practical matter, you obtain a patient's informed consent for simple procedures when you explain the procedure to him before you begin. The patient may then give you express consent or implied consent to proceed. For example, let's say you're about to take an X-ray. You first explain what you're doing and ask if he'll let you begin. If he says, "Sure," that's express consent. If he silently offers to go with you for the X-ray, that's implied consent.

For routine procedures you can assume that the patient implies consent as long as they don't object. But to be on the safe side, always document the fact that you explained the procedure and that the patient consented to it-no matter how he gave the consent. Of course, a patient may refuse to submit to a procedure, or withdraw consent after he's given it. Document his refusal right away.

What if the patient withdraws consent while you're in the middle of a procedure? That's a judgment call. As a rule, you should stop immediately-unless doing so would jeopardize the patient's welfare.

Every invasive or risky procedure requires express informed consent, which can come in the form of either a written or an oral statement. A written statement isn't necessarily required by law (except in something such as clinical research projects). But many healthcare providers insist on a written statement anyway because it documents the patient's consent, especially for any invasive or risky procedures.

In most cases, you will inform the patient about procedures either through verbal or written information. But, how much information should be provided? The law specifies only that you must disclose enough information for the patient to make an informed choice. As a rule, then, you should explain the patient's diagnosis, the name of the procedure or treatment, how it will benefit the patient, what risks it involves, what alternatives exist and what the patient's prognosis will be if the procedure isn't done.

If a legal dispute arises later, the court can measure a dentist's disclosure against the reasonable standard of care, which is based on what a reasonable dentist would tell a similar patient in a similar situation. As an alternative, the court could apply the reasonable patient standard, which approaches the issue from a slightly different perspective: What would a reasonable patient want to know before making a decision?

But what about the original question-are you liable if you accept the signature and perform the procedure without really informing the patient? In this case, probably not. Any competent adult patient can waive his right to be informed, and you must respect that decision. But you should tell the patient what risks and alternatives exist and offer to discuss them if the patient changes his mind. And, of course, always document the discussion and the waiver in the their file.

Here's another important point: If the patient changes his mind and tells you he wants more information, you should give it to him immediately. Document his request and talk to him again before performing the procedure.

Responsibilities with special circumstances vary among states, so make sure you understand state law on the consent process. If you have questions, check with a lawyer.

Here are some special situations that may occur:

• Minors

The parents or guardian must give consent before a minor is treated. If the parents are divorced, determine which parent has the right to consent to any treatment and document the facts.

• Guardianship

If a court has formally declared a patient incompetent, a court-appointed guardian of the person has the power to make decisions for him. You may be expected to confirm that the guardian has the power to give consent for the patient's treatment. If possible, place a copy of the court order appointing the guardian in the patient's file and document the guardianship in your notes.

• Language Barrier

The explanation and the consent form should be in the patient's language. Also, consider having a translator present during the consent process and document it. Document the translator's name and other information on the consent form and in your notes.

The consent process can prevent a lawsuit. But more importantly, it protects the patient's right to make a knowledgeable choice about his own treatment. By participating in the consent process, you act as patient advocate while simultaneously meeting your legal obligations. When you follow both the letter and the spirit of the law, everyone comes out ahead.

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