The record of informed consent is often your primary defense when a patient claims you failed to warn them of potential risks and alternative treatments. However, that defense only works if your documentation is complete and precise.
The case of Williams v. Levine
In Williams v. Levine (2025), two surgeons performed surgery on a patient. After some time, when the surgery failed to improve her condition and instead worsened it, she filed a lack of informed consent claim against the surgeons and the medical institutions they were affiliated with. However, the court dismissed that claim when the defendants produced thoroughly documented evidence showing that they made the required statutory disclosures.
The legal compulsion to document everything
Beyond serving as a key defense in court, state and federal law requires that you maintain complete medical documentation. Under New York Public Health Law, you must obtain and document informed consent for two specific types of care:
- A nonemergency treatment, procedure or surgery
- A diagnostic procedure that involves invasion or disruption of the body’s integrity
Federal regulations also require hospitals to maintain a dedicated medical records service to keep records secure and confidential for at least five years. However, New York State law sets a stricter standard, requiring that hospitals keep adult hospital records for at least six years after discharge.
Risk mitigation as an ongoing legal priority
The outcome of claims like Williams v. Levine highlights that liability protection is built long before a lawsuit is ever filed. Adhering to strict record-retention timelines ensures that the physical record remains intact when needed most. Ultimately, aligning daily administrative habits with legal standards can create a shield against future malpractice claims.
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