When the patient/surrogate has provided specific written consent, the consent form should be included in the record. Document the informed consent conversation and the patient’s (or surrogate’s) decision in the medical record in some manner.The burdens, risks, and expected benefits of all options, including forgoing treatment.The nature and purpose of recommended interventions.The physician should include information about: Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information.Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.In seeking a patient’s informed consent (or the consent of the patient’s surrogate if the patient lacks decision-making capacity or declines to participate in making decisions), physicians should: The process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.
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