Informed consent documentation - Revision history

Rossdonaldson1: /* Exceptions to Informed Consent */

2026-03-25T20:15:49Z

Exceptions to Informed Consent

← Older revision		Revision as of 20:15, 25 March 2026
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	==Exceptions to Informed Consent==		==Exceptions to Informed Consent==
	*~~'''~~Emergency exception~~'''~~ — life-threatening condition, patient lacks capacity, no surrogate available		*Emergency exception — life-threatening condition, patient lacks capacity, no surrogate available
	*~~'''~~Implied consent~~'''~~ — patient presents for care and cooperates with minor interventions		*Implied consent — patient presents for care and cooperates with minor interventions
	*~~'''~~Therapeutic privilege~~'''~~ — rarely invoked; information withheld if disclosure would seriously harm the patient		*Therapeutic privilege — rarely invoked; information withheld if disclosure would seriously harm the patient
	*~~'''~~Patient waiver~~'''~~ — patient explicitly waives right to be informed		*Patient waiver — patient explicitly waives right to be informed

	==Consent for Minors==		==Consent for Minors==

Rossdonaldson1: /* Elements of Valid Informed Consent */

2026-03-25T20:15:16Z

Elements of Valid Informed Consent

← Older revision		Revision as of 20:15, 25 March 2026
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	==Elements of Valid Informed Consent==		==Elements of Valid Informed Consent==
	*~~'''~~Nature of the procedure~~'''~~ — what will be done, in understandable language		*Nature of the procedure — what will be done, in understandable language
	*~~'''~~Indications~~'''~~ — why the procedure is recommended		*Indications — why the procedure is recommended
	*~~'''~~Risks~~'''~~ — common risks AND rare but serious risks (e.g., bleeding, infection, nerve injury, death)		*Risks — common risks AND rare but serious risks (e.g., bleeding, infection, nerve injury, death)
	*~~'''~~Benefits~~'''~~ — expected outcomes		*Benefits — expected outcomes
	*~~'''~~Alternatives~~'''~~ — including the option of no intervention		*Alternatives — including the option of no intervention
	*~~'''~~Questions~~'''~~ — opportunity for the patient to ask questions		*Questions — opportunity for the patient to ask questions
	*Document that patient ~~'''~~understood~~'''~~ and ~~'''~~agreed~~'''~~ to proceed		*Document that patient understood and agreed to proceed

	==Exceptions to Informed Consent==		==Exceptions to Informed Consent==

Rossdonaldson1: /* Background */

2026-03-25T20:14:34Z

Background

← Older revision		Revision as of 20:14, 25 March 2026
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	==Background==		==Background==
	*Informed consent is a legal and ethical requirement before performing procedures
	*In the ED, consent may be verbal or written depending on procedure risk and institutional policy		*In the ED, consent may be verbal or written depending on procedure risk and institutional policy
	*~~'''~~Implied consent~~'''~~ applies to emergency, life-saving procedures when the patient lacks capacity and no surrogate is available<ref>Moskop JC. Informed consent and refusal of treatment: challenges for emergency physicians. Emerg Med Clin North Am. 2006;24(3):605-618.</ref>		*Implied consent applies to emergency, life-saving procedures when the patient lacks capacity and no surrogate is available<ref>Moskop JC. Informed consent and refusal of treatment: challenges for emergency physicians. Emerg Med Clin North Am. 2006;24(3):605-618.</ref>
	*A patient must have ~~'''~~decision-making capacity~~'''~~ (not the same as legal competence) to provide valid consent		*A patient must have decision-making capacity (not the same as legal competence) to provide valid consent
	*Consent is a ~~'''~~process~~'''~~, not just a form — the discussion matters more than the signature		*Consent is a process, not just a form — the discussion matters more than the signature

	==Elements of Valid Informed Consent==		==Elements of Valid Informed Consent==

Rossdonaldson1: /* Capacity Assessment */

2026-03-25T19:45:04Z

Capacity Assessment

← Older revision		Revision as of 19:45, 25 March 2026
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	==Capacity Assessment==		==Capacity Assessment==
	*Four components of decision-making capacity:		*Four components of decision-making capacity. The patient must be able to:
	**~~Able to '''understand'''~~ the relevant information		**Understand the relevant information
	**~~Able to '''appreciate'''~~ the situation and consequences		**Appreciate the situation and consequences
	**~~Able to '''reason'''~~ through options		**Reason through options
	**~~Able to '''communicate'''~~ a choice		**Communicate a choice
	*Capacity is ~~'''~~task-specific~~''' — a~~ patient may have capacity for one decision but not another		*Capacity is task-specific
	*Capacity can ~~'''~~fluctuate~~'''~~ (e.g., intoxication, delirium)		**A patient may have capacity for one decision but not another
			*Capacity can fluctuate (e.g., intoxication, delirium)
	*If capacity is uncertain, err on the side of treatment in emergencies		*If capacity is uncertain, err on the side of treatment in emergencies
	*See also [[Against medical advice]] for capacity documentation in the AMA context		*See also [[Against medical advice]] for capacity documentation in the AMA context

Rossdonaldson1: /* See Also */

2026-03-25T19:15:06Z

Danbot: New page: Informed consent documentation with elements, exceptions, minors, capacity assessment, sample documentation

2026-03-24T10:58:37Z

New page: Informed consent documentation with elements, exceptions, minors, capacity assessment, sample documentation

New page

==Background==
*Informed consent is a legal and ethical requirement before performing procedures
*In the ED, consent may be verbal or written depending on procedure risk and institutional policy
*'''Implied consent''' applies to emergency, life-saving procedures when the patient lacks capacity and no surrogate is available<ref>Moskop JC. Informed consent and refusal of treatment: challenges for emergency physicians. Emerg Med Clin North Am. 2006;24(3):605-618.</ref>
*A patient must have '''decision-making capacity''' (not the same as legal competence) to provide valid consent
*Consent is a '''process''', not just a form — the discussion matters more than the signature

==Elements of Valid Informed Consent==
*'''Nature of the procedure''' — what will be done, in understandable language
*'''Indications''' — why the procedure is recommended
*'''Risks''' — common risks AND rare but serious risks (e.g., bleeding, infection, nerve injury, death)
*'''Benefits''' — expected outcomes
*'''Alternatives''' — including the option of no intervention
*'''Questions''' — opportunity for the patient to ask questions
*Document that patient '''understood''' and '''agreed''' to proceed

==Exceptions to Informed Consent==
*'''Emergency exception''' — life-threatening condition, patient lacks capacity, no surrogate available
*'''Implied consent''' — patient presents for care and cooperates with minor interventions
*'''Therapeutic privilege''' — rarely invoked; information withheld if disclosure would seriously harm the patient
*'''Patient waiver''' — patient explicitly waives right to be informed

==Consent for Minors==
*Generally requires consent from parent or legal guardian
*Exceptions vary by state but commonly include:
**Emancipated minors (married, military, court-ordered)
**Mature minor doctrine (jurisdiction-dependent)
**Emergency care
**Reproductive health, STI testing/treatment, substance abuse treatment (state-dependent)

==Capacity Assessment==
*Four components of decision-making capacity:
**Able to '''understand''' the relevant information
**Able to '''appreciate''' the situation and consequences
**Able to '''reason''' through options
**Able to '''communicate''' a choice
*Capacity is '''task-specific''' — a patient may have capacity for one decision but not another
*Capacity can '''fluctuate''' (e.g., intoxication, delirium)
*If capacity is uncertain, err on the side of treatment in emergencies
*See also [[Against medical advice]] for capacity documentation in the AMA context

==Sample Documentation==

===Standard Procedural Consent===
Informed consent obtained from @NAME@. The procedure (_____), including the indications, risks (including but not limited to bleeding, infection, pain, nerve/vessel injury, need for further intervention, and _____), benefits, and alternatives (including no intervention) were discussed in language the patient could understand. The patient was given the opportunity to ask questions, which were answered to their satisfaction. The patient expressed understanding and agreed to proceed with the procedure.

===Emergency Consent (Patient Lacks Capacity)===
The patient requires emergent _____ for _____. The patient is unable to provide informed consent due to ___ (altered mental status, intubation, cardiac arrest, etc.). No surrogate decision maker is immediately available. Given the emergent, life-threatening nature of the condition, the procedure was performed under implied/emergency consent in the patient's best interest per the emergency exception doctrine.

===Consent via Surrogate===
@NAME@ lacks decision-making capacity due to _____. Informed consent was obtained from _____ (relationship: _____), who is the patient's healthcare proxy/next of kin/legal guardian. The procedure, risks, benefits, and alternatives were discussed. The surrogate expressed understanding and provided consent on the patient's behalf.

==See Also==
*[[Documentation for emergency physicians]]
*[[Procedure sample documentation]]
*[[Against medical advice]]

{{Documentation pages}}

==References==
<references/>

[[Category:Documentation]]

← Older revision		Revision as of 19:15, 25 March 2026
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	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[Procedure sample documentation]]
	*[[Against medical advice]]

	{{Documentation pages}}		{{Documentation pages}}