Page 97 - Registrar Orientation Manual 2016

Document reference:
1969
Effective date:
30 Mar 2010
Expiry date:
01 Jun 2013
Page:
5 of 24
Title:
Informed consent
Type:
Policy
Version:
03
Authorising initials:
1.2. Documentation of the informed
consent process
patient;
- respect the patient’s dignity e.g. in out-patient clinics, where
practical, patients should be encouraged to dress in their own clothes and be comfortably seated before discussion of diagnosis and treatment options occurs.
- respect the patient’s cultural and personal needs e.g. support the involvement of family / whānau in discussions if appropriate
- provide information to the patient in a language, form and manner that the patient can easily understand. Where necessary it should be translated into the patient’s own language.
- use published material where it could be helpful in providing the information needed.
- allow sufficient time for the patient to read written information, and speak with their family or friends if they wish to do so.
- advise patients that they have a right to have another person
present during the discussion related to the proposed treatment
or procedure.
- encourage the patient to ask questions or suggest alternative
points of view.
 Some patients may not want to discuss the details of a procedure. The healthcare professional should explain to the patient that they cannot proceed with the procedure without providing the information that a reasonable patient would wish to have about the procedure.
 If there is a consent form(s) available for the proposed treatment or procedure, this should be completed and placed on the clinical file.
 If a form is not available to document consent, the clinician or delegate is required to make clear and accurate notes about the consent process. This may include the following:
- what information was provided to the patient, when, by whom and who else was present
- questions asked by the patient and the answers given
- specific wishes of the patient
- who gave the consent i.e. whether it was the patient or the
person acting on his / her behalf
- what treatment or procedure that consent was given for.
 Where the patient has declined to give their informed consent, this shall be documented in the clinical record.
 Refer to section 2.1 below on the circumstances in which written consent is required.
 The patient must be provided with the information that a reasonable consumer, in that consumer’s circumstances, needs to make an informed choice and as a result give informed consent. As a minimum the patient should be provided with information on the following:
- their condition, together with any findings from investigations already carried out
- the options available for treating their condition – important
1.3. What is sufficient information?