How should athletic trainers document a patient’s consent?

• A. Verbal note only with no date
• B. In a separate consent form stored off-site
• C. In the medical record with date and signature or other approved method
• D. Not necessary if the patient agrees verbally

Answer: (C)

Documenting informed consent is essential before providing any evaluation or treatment. The record should show that the patient was informed about the procedure, its risks, benefits, and alternatives, and that they agreed to proceed. This consent is best documented in the medical record with a date and the patient's signature, or through an approved method such as electronic or witnessed consent. Having it in the medical record creates a clear, verifiable trail that protects both the patient’s rights and the clinician, supports continuity of care, and satisfies legal and ethical requirements. Verbal notes without a date don’t provide verifiable authorization, storing consent in a separate off-site location can impede access when care is needed, and consent isn’t unnecessary just because the patient verbally agrees. If the patient is a minor or unable to consent, a guardian’s consent should be documented in the same way.