This is because, legally, the practitioner is responsible for ensuring that the patient is properly informed and consents to the procedure. In order to be able to prove this in the event of a dispute, the informed consent must be documented - ideally in such a way that it can still be retraced years later.
The documentation of information and consent, which is mandatory in any case, can be done in different ways. A photocopy of a sample form is particularly meaningful if it contains handwritten underlining, notes or tick marks that indicate a personal discussion about these contents. It is even better if the content of the conversation is also summarised by hand in a text field and the parties sign it at the end - because this is exactly what helps to provide evidence in an emergency.
The Federal Court of Justice (judgement of 5 November 2024 - VI ZR 188/23) recently stated that it is not sufficient for the doctor to refer to forms and information sheets that he has had the patient sign and that this may also contradict the nature and purpose of patient information as a confidential discussion between the doctor and patient. In the informed consent discussion, the doctor must ensure that the patient has understood both the verbal and written instructions and information and, if necessary, address the patient's individual concerns and answer any questions. Only then is it a case of proper information.
Conclusion:
Information requires a trusting dialogue between doctor and patient. Sample forms are still useful as evidence of this dialogue in the event of a dispute.
Dr Christoph Bialluch