GMC Guidelines illustrate the importance of documenting key elements of a consultation such as side effects of medication and an assessment of patient's capacity. Not documenting this information makes a clinician liable if complications arise as there is no evidence of a discussion taking place. Do clinicians document this important information? Our aim was to look for evidence of:
An assessment of patients capacity to consent.
A discussion taking place regarding side effects.
This was from 6 Consultant teams. We also looked to evaluate the effect of measures introduced to improve practice.