Ob-Gyn Coding Alert

Reader Question:

Informed Consent for Ultrasounds

Question: We do a lot of ultrasounds on non-ob patients when the diagnosis is pelvic pain. Is there any reason to get a signed consent form from the patient in case something is discovered in surgery that we didn't diagnose from the ultrasound?

New York Subscriber

Answer: The premise behind informed consent is that the patient is made aware of all the risks to her health if she consents to have surgery or a procedure performed. Informed consent would not cover cases where you found something at surgery that was not present on the ultrasound exam (which will be limited). So no, you should not get an informed consent signed for the ultrasound exam (especially because it is a procedure without risk to the patient), but of course you will get one signed for any surgery that is intended, and at that time you may mention that something may be found that was not evidenced by the diagnostic tests previously performed.