tut 2 consent

Question 1

what r the ways of giving consent

Answer 1

Consent can be given in 3 ways:
• Impliedly
•Expressly – verbally
•Expressly – in writing

Question 2

validity of consent

Answer 2

Validity of consent:
• Any consent given is freely and voluntarily
• Any consent given in properly informed
• The person giving consent has the legal capacity to give it

Question 3

what do you mean by Any consent given is freely & voluntarily given

Answer 3

• Free from coercion or duress
• Avoid advising patients that they MUST have a procedure
before they can be discharged
• Avoid taking the position that ‘I know what is best for you’

Question 4

Consent given is properly informed questions to consider

Answer 4

Two questions to consider are:
1. How much information does the patient require to make a decision to consent to treatment?
• What does the procedure involve? Why is it necessary? • What are the risks? How likely are they to occur?
2. Who is responsible for giving information to a patient?
• The treating practitioner: medical officer, nurse practitioner, midwife.

Question 5

The person giving consent has the legal capacity to give such consent

Answer 5

yes
• Any person over 18 years of age, barring any mental incapacity may give consent
• >14 years

No
• Adults who lack the intellectual capacity to make a decision
• An involuntary patient deemed to be mentally ill
• <14 years

Question 6

confidentiality

Answer 6

• You are permitted to divulge information on a need to know basis in the course of performing your work, unless you have written authority to do otherwise, or you are required by law e.g. mandatory reporting of child abuse, notifiable disease.
• Medical records are confidential documents, the contents of which should only be divulged in the course of your working duties
• Conversations about clients must not be conducted in the presence of, or be overheard by, those not entitled to know the information in the performance of their daily duties.
• Disclosure of information over the phone should be limited and undertaken in accordance with health service policy.
• It is your individual responsibility to maintain confidentiality when you have access to, or knowledge of, confidential information

Question 7

Documentation

Answer 7

• No entry concerning the patient’s treatment can be made on behalf of another nurse
• Documentation should be contemporaneous – as close to the time of occurrence as possible
• Any errors occurring whilst writing an entry should be crossed through and initialed before continuing with your entry
• White-out or correction fluid must never be used

• When documenting always use the current time and date of the entry,
avoid rounding time up or down

• Document statements of fact: objective rather than subjective information

Question 8

documentation from

From NSW Health ‘Principles for creation, management, storage, disposal of health care records’ (2008)

Answer 8

• Individual record: record is made at time of patients first attendance and every subsequent attendance must be recorded
• Continuity of care: documentation promotes continuity
• Confidentiality
• Authenticity: all entries are statements of fact or clinical judgment relating to care
• Relevance: records are not to contain prejudicial, derogatory or irrelevant statements
• Completeness: entries must be chronological
• Responsibility for documentation: The health professional providing care/assessment/clinical judgment must legibly document
• Timeliness of documentation: contemporaneous (as close to the time of the event/care/assessment as possible)
• Ownership: health record is the property of the health service providing care

• Access: the person to whom the care relates, those providing care, if required
by law/policy

• Quality improvement, review, evaluation and research
• Durability
• Storage & Security: Must be stored in a secure place
• Retention: Held for a period of time in accordance with law
• Disposal: disposed of in such a manner as to maintain confidentiality.