Consent to Healthcare and Documentation
Please refer to PHSA Consent to Healthcare Policy and PHSA – Consent to Health Care: Procedure for Adults who Demonstrate Capability for details around patient consent to healthcare and the laws that form the basis for these policies. Depending on the Most Responsible Providers’ (MRP) assessment of the degree of risk involved with the Health Care and complexity of the Consent discussion, document the following information that is relevant to the particular Consent decision:
- Major risks discussed;
- Minor but important risks mentioned;
- Questions the Adult asked;
- Answers provided;
- Any additional information or consultation provided to meet the cultural needs of the Adult;
- Verification of the Adult’s apparent understanding;
- If a language barrier existed, confirmation that a qualified interpreter, family member or interpreter service through dispatch as appropriate, was used to facilitate the Consent communication;
- If applicable, barriers to communicating with the Adult and the steps taken to overcome these barriers such as consultation with others (friend, other HCP) in helping the Adult understand the information.