Patient Authorisation to discuss Medical Records with a Named Person (Over 18 yrs ONLY)
To enable our Doctors to discuss medical records including results and appointment information with someone else (i.e. a relative) you will need to complete a consent form.
Please download the form Patient Authorisation Consent Form complete, sign and send via email to firstname.lastname@example.org This information will be recorded onto your medical record.
Without signed consent we will be unable to discuss another person’s medical record.
Laurel House Surgery Patient Consent Policy
The purpose of this policy is to set out the Practice’s approach to consent and the way in which the principles of consent will be put into practice.
Where possible, a clinician must be satisfied that a patient understands and consents to a proposed treatment, immunisation or investigation.
The clinician must also ensure that other possible treatment options, including the risks and benefits of each, have been explained to the patient before the patient makes their decision to consent.
Where a patient is accompanied by a carer, advocate or other support person, the clinician will ensure that:
· they understand the care, treatment and support choices available to the patient;
· involve them appropriately in making decisions about the patient’s care;
· give opportunities for them to represent the views of the patient;
Whether explaining to a patient, carer, advocate or other support person; information given will include the nature, purpose, and risks of the procedure. If necessary, the use of drawings, interpreters, videos or other means will also be used to ensure that they understand, and have enough information to give ‘Informed Consent’.
The Practice will ensure that where consent is necessary, the forms contained within this document will be completed and the action noted on the patient record.
The Practice will undertake an audit annually to determine that consent is always sought and recorded in-line with this policy.
Implied consent will be assumed for many routine physical contacts with patients.
Where implied consent is to be assumed by the clinician, in all cases, the following will apply:
· An explanation will be given to the patient what s/he is about to do, and why.
· The explanation will be sufficient for the patient to understand the procedure.
· In all cases where the patient is under 18 years of age, a verbal confirmation of consent will be obtained and briefly entered into the medical record.
· Where there is a significant risk to the patient an ‘Expressed Consent’ will be obtained in all cases.
Expressed consent (written or verbal) will be obtained for any procedure which carries a risk that the patient is likely to consider as being substantial.
A note will be made in the medical record detailing the discussion about the consent and the risks.
A Consent Form may be used for the patient to express consent.
• Consent (Implied or Expressed) will be obtained prior to the procedure, and prior to any form of sedation.
• The clinician will ensure that the patient is competent to provide a consent (16 years or over) or has “Gillick Competence” if under 16 years.
Further information about Gillick Competence and obtaining consent for children is set out below.
• Consent will include the provision of all information relevant to the treatment.
• Questions posed by the patient will be answered honestly, and information necessary for the informed decision will not be withheld unless there is a specific reason to withhold. In all cases where information is withheld, then the decision will be recorded in the clinical record.
• The person who obtains the consent will be the person who carries out the procedure (i.e. a nurse carrying out a procedure will not rely on a consent obtained by a doctor unless the nurse was present at the time of the consent).
• The person obtaining consent will be fully qualified and will be knowledgeable about the procedure and the associated risks.
• The scope of the authority provided by the patient will not be exceeded unless in an emergency.
• The Practice acknowledges the right of the patient to refuse consent, delay the consent, seek further information, limit the consent, or ask for a chaperone.
• Clinicians will use a Consent Form where procedures carry a degree of risk or where, for other reasons, they consider it appropriate to do so (e.g. malicious patients).
• No alterations will be made to a Consent Form once it has been signed by a patient.
• Clinicians will ensure that consents are freely given and not under duress (e.g. under pressure from other present family members etc.).
• If a patient is mentally competent to give consent but is physically unable to sign the Consent Form, the clinician should complete the Form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally.
Other aspects which may be explained by the clinician include:
• Details of the diagnosis, prognosis, and implications if the condition is left untreated.
• Options for treatment, including the option not to treat.
• Details of any subsidiary treatments (e.g. pain relief).
• Patient experiences during and after the treatment, including common or potential side effects and the recovery process.
• Probability of success and the possibility of further treatments.
• The option of a second opinion.
Informed consent must be obtained prior to giving an immunisation. Although there is no legal requirement for consent to immunisation to be in writing, a signature on a consent form is not conclusive proof that consent has been given, but serves to record the decision and discussions that have taken place with the patient, or the person giving consent on a child’s behalf.
Consent for Children under 16 (Gillick Competence)
Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated.
If a child under the age of 16 has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself.
Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign a Consent Form for themselves, but may like a parent to countersign as well.
For children under 16 (except for those who have Gillick Competence as noted above), someone with parental responsibility should give consent on the child’s behalf by signing accordingly on the Consent Form.
Withdrawal of Patient Consent
• The Practice acknowledges the right of the patient to refuse consent, delay consent, seek further information, limit the scope of consent, or ask for a chaperone.
• The patient or parent / guardian has the right to withdraw consent at any time.
• A Withdrawal of Patient Consent Form will be required to be completed and documented on the patient’s medical record
• Questions posed by the patient will be answered honestly, and information necessary for them to make an informed decision will not be withheld unless there is a specific reason to withhold it. In all cases where information is withheld, the reasons for this will be recorded in the patient’s clinical record.
• The person who would have been carrying out the procedure will make sure that all issues around the withdrawal of consent have been fully explained to the patient or parent / guardian to enable them to fully understand what may happen if the treatment / operation is not carried out. (The person discussing this must be fully qualified and knowledgeable about the procedure itself and the associated risks).
• The scope of the authority provided by the patient will not be exceeded unless in a medical emergency.
• No alterations will be made to the withdrawal of Consent Form once it has been signed by a patient.
• If a patient is mentally competent to withdraw consent but is physically unable to sign the form, the clinician should complete the form as usual, and ask an independent witness to confirm that the patient has confirmed they wish to withdraw their consent orally or non-verbally.