Informed Consent and Patient Rights 2

Informed Consent

The process by which a patient learns about and understands the purpose, benefits, and risks of a medical or surgical intervention, then agrees to receive it.

Implied Consent

Patient consent for routine procedures is implied by acceptance (no form needed).

Written Consent

A signed form is required for any procedure that’s invasive, experimental, or involves substantial risk.

Requirements for Legal Informed Consent

1. Patient has received full explanation (risks & benefits).

2.  Patient is competent to sign.

3. Only parents/legal guardians may sign for minors or incompetent patients.

4. Patient must sign before sedation/anesthesia.

5.  Form must be complete before signing (no blanks).

6.  Only the physician named on the form may perform the procedure.

7.  Any stated conditions must be met (e.g., family presence).

8.  Patient may revoke consent anytime during procedure.

Medical Chart

A patient’s chart is a legal document, may be used in court, and establishes a pattern of behavior.

Documentation Requirements

Must be complete, objective, consistent, legible, and accurate.

Medical Chart Must Contain

Allergies, advanced directive, patient’s condition, diagnosis/impression, and vital signs.

Radiographs

Medical records that must be kept 5–7 years for adults; for minors, kept 5–7 years after they reach age 18.

Release of Radiographs

Requires patient signature; may be mailed or given to patient to hand carry.

Patient’s Rights

Outlined in the AHA Patient’s Bill of Rights (guideline, not law). Includes:

1. Right to information (understandable/accurate health info).

2. Right to choose providers/plans.

3. Right to access emergency services.

4. Right to participate in treatment decisions.

5. Right to respect and non-discrimination.

6. Right to confidentiality.

7. Right to grievance and appeals.

Patient Confidentiality

Right of the patient to keep medical records private.

Protected Health Information (PHI)

Includes demographics, medical history, test results, mental health, insurance info, etc.

HIPAA

Health Insurance Portability and Accountability Act of 1996; sets national standards to protect patient health information.