Consent systems and records

Do you have a system for clinical consent? Just as you have a system for taking your case history that enables you to follow a logical pattern, covering all the points you need, I suggest you need a system for clinical consent.

The benefits of a system

Following a system enables you to make sure that you have covered all the necessary bases. It does not mean that every patient experience is exactly the same. Your consent processes must be individualised to the patient in front of you and their situation – just as your case history is.

Analyse your consent

A really interesting exercise which you may have done as a student is to analyse how you come to diagnostic decision. There are many factors used – clinical experience, patient preferences, evidence based, hypothesis testing etc.

In a similar way you can study your consent process. Consent is the whole patient journey. There will be information provided before treatment, during the case history, during examination and throughout treatment. The key aspects to valid consent are:

  • Making sure the patient is voluntarily participating in the journey
  • Informing the patient – this often happens as an ongoing process at multiple points
  • Ensuring the patient has capacity to consent

 Thinking of your consent process in terms of the whole patient journey will probably make you amazed at how many consent based actions there are – from the initial patient contact to the end of the treatment plan.

Essential components of consent

Within your patient journey you should be able to identify:

  1. The patient was informed of their right to have a chaperone present
  2. The patient was informed of their right to stop examination or treatment at any time
  3. The patient’s expectations were identified and matched to the osteopath’s abilities
  4. Care options were explained to the patient
  5. The patient had opportunity to ask questions
  6. Benefits and material or significant risks were explained to the patient and understood.
  7. You are reassured the patient was attending in a voluntary capacity
  8. The patient was involved in the treatment plan and free to accept or refuse proposed examination or treatments
  9. The patient had all the information they needed and understood details and implications of the treatment plan
  10. The patient is encouraged to express concerns and knows how to stop treatment
  11. Children and parents are actively involved in the consent process
  12. Records include – key elements of the discussion with the patient, information discussed, concerns raised, expectations, request for information, how you addressed these, any decisions made
  13. Data consent procedures are in place

Intimate areas:

The patient understood and consented to the proposed examination or treatment

A chaperone was offered

The patient was offered to postpone the procedure to a subsequent appointment

How to document your system

Having a system for recording consent can be really helpful. It will help you to make sure you fulfill all the requirements of consent. You will be able to easily identify areas that are missing or need more explanation. This is not a tick box exercise. Just like your case history it is a recording method that is robust to make sure your patient records arecomplete.

You can go through each of the 13 points mentioned above and the intimate area consent if appropriate. Ask yourself at what point or often several points on the patient journey that aspect of consent is fulfilled and where would that be documented. You should be able to easily identify all ofthese components on your case history.

Have a system to make sure your records are robust and fully completed. Modify your case history if you feel there are areas that may be overlooked especially if there is no particular area to record some details.

Could you answer these questions from your clinical record?

You could turn this into an audit of your patient records for your CPD. Take a number of records and go through the 13 points above assessing whether they are identifiable on your case history. Don’t just look at the initial appointment but consider ongoing consent and returning patients. Turn the 13 points into questions:

  1. How do I know the patient was informed of their right to have a chaperone present?
  2. How do I know the patient was informed of their right to stop examination or treatment at any time?
  3. What were the patient’s expectations and how did they match with what osteopathy can provide? – is there a record of the discussion
  4. What care options were explained to the patient?
  5. How do I know the patient had opportunity to ask questions?
  6. What benefits and material or significant risks were explained to the patient and were they understood?
  7. Are you reassured the patient was attending in a voluntary capacity? Where would you record concerns or a conversation to confirm voluntary attendance if it took place?
  8. How do I know the patient was involved in the treatment plan and free to accept or refuse proposed examination or treatments? What was discussed? What is the treatment plan?
  9. Did the patient had all the information they needed and understood details and implications of the treatment plan? – Did they have any questions, how were they responded to?
  10. How is the patient encouraged to express concerns and do they know how to stop treatment?
  11. How does my record show children and parents were actively involved in the consent process?
  12. Do my records include – key elements of the discussion with the patient, information discussed, concerns raised, expectations, request for information, how I addressed these, and any decisions made?
  13. How do I know data consent procedures are in place and used?

In my opinion having robust clinical consent procedures is fundamental to good clinical practice. Take the time to look at your procedures and make sure you have all the necessary components.

Leave a Reply

Your e-mail address will not be published. Required fields are marked *