informed consent

Question 1

what is informed consent

Answer 1

document signed by pt before invasie procedures

exceptions: bladder cathetrization, NG intubation and venipuncture

exception in ED: when need for consent outweighed by need for urgent intervention

by doc b4 procedure

Question 2

components of informed consent

Answer 2

diagnosis
proposed treatment or procedure
alternative treatment options: surgical or medical, with risks + benefits
risk and benefit of treatment
risk of refusing treatment

Question 3

informed consent and patient autonomy

Answer 3

pt should understand procedure
give pt time to decide
pt has right to ask questions and know who else will be in room (and can ask them to leave)
pt has right to refuse procedure
pt may want third party in room or not

consent form should remain w/ chart; additional documentation about change in treatment plans will need to be included

Question 4

library resources to identify risks assoc w/ common procedures

Answer 4

CLinical Key

Procedures for primary care book (pfenniger)

clinicans pocket reference

Question 5

basic components of procedure note

Answer 5

what was procedure
indications for it
permission given (and note risk/benefits explained)
physicians, other present
description of procedure (type of positioning, prep, anesthesia type and amt)
complications if any
estimated blood loss 
specimens/findings obtained
disposition (pt status after procedure)

Question 6

diff bw procedure note and SOAP note

Answer 6

The soap note will contain the specific information about the lesion, size, location, induration, warmth, etc.