Informed Consent

Informed consent

The process by which a patient learns about and understands the purpose, the benefits & any potential risks of a medical or surgical intervention

• Implied by acceptance for routine procedures

• Signed form for procedures that are invasive, experimental & involve substantial risk

Informed consent is legal if…

1. patient received full explanation of procedure + risks & benefits

2. patient must be competent to sign an informed consent

3. only parents or legal guardian may sign for minor or mentally incompetent patient

4. patient has signed form before sedation or anesthetization

5. form completed prior to patient signing (parent/guardian cannot sign incomplete form)

6. only the physician named on form can perform procedure

7. all conditions stated on form must be met

8. patient may revoke consent at any time! (A RIGHT)

Patient chart…

• legal document

• may be used in court cases

• establishes pattern of behavior

• only read to seek/add information

Documentation must be…

• complete

• objective

• consistent

• legible

• accurate

Documentation must contain

• allergy information

• advanced directive

• patient’s current condition

• diagnosis or impression

• vital signs

Radiograph as medical records

• adult x-rays kept 5-7 years

• minor’s x-rays kept 5-7 years AFTER they reach 18 (legally an adult)

• release requires patient signature

• records may be sent by mail, w/ patient to hand carry OR by encrypted link

Patient’s Bill of Rights

American Hospital Association (AHA) created the Patient’s Bill of Rights

• guideline, not law

• can be found in Learning Zone Patient Care Homepage/Handbook

Right To…

1. information (understandable & accurate)

2. choose providers & plans

3. access emergency services

4. participation in treatment decisions

5. respect & non-discrimination

6. confidentiality

7. grievance & appeals

Patient confidentiality

Right of the patient to keep their medical records private

PHI

• protected (personal) health information

• demographics, medical history, test & laboratory results, mental health conditions, insurance information & other data

HIPAA

• Health Insurance Portability & Accountability Act of 1996

• federal law that required the creation of national standard to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge