Consent and records: the minimum that protects you
UniDent editorial team · July 28, 2026
Medically reviewed by: Dr Aleks Aleksiev · reviewed July 28, 2026
Consent is not a signature on a form but a conversation that left a trace. Records are not bureaucracy but the only evidence of what was explained and done. Both take minutes; their absence costs far more.
Consent is a conversation, not a document
The patient has to understand what is coming, what the alternatives are and what can go wrong — in language they actually use. A form signed without that conversation is not informed consent; it is just a signature.
What gets written down
- History: medicines, allergies, medical conditions.
- What was explained to the patient and what they chose.
- What was done, with which materials, approved by whom.
- Aftercare instructions given.
Write it immediately
A note written in the evening is a reconstruction. After three patients the details blur, and the detail is precisely what matters if anyone asks months later.
The patient’s data is not yours
Photographs, radiographs and notes are personal data, and health data is a special category. They do not travel through personal chats, do not live in your phone’s camera roll, and are not shown to anyone without a reason.
What to do next
- Ask what the informed-consent procedure is in your department.
- Write your notes immediately after the procedure, not that evening.
- Clear your phone of any patient images you have no reason to keep.
Sources
- Health Act — informed consent (public information)
- Regulation (EU) 2016/679 (GDPR)