ULO 11- Informed Consent and Confidentiality Flashcards
Define: Consent
is permission given by people for tests and procedures to be carried out
What forms does consent take
written
verbal
non-verbal
implied
Define: Informed consent
is when reasonable efforts have been made to ensure that the person concerned has the information they need to understand what they are consenting to
What are the Principles of Informed Consent
consent should:
- be freely given (not coerced, pressured or intimidated)
- only be sought from a person who has capacity to consent
- should be timely
When should consent be recorded
when it is informed and always
Define: Implied Consent
means that a person has not explicitly (verbally or written) given their agreement, but conduct/behaviour have “implied consent”
In Continuity of Care, what are the rules around consent?
consent must
- be sought when approaching the women about continuity of care
- be informed
Define: Confidentiality
is the protection of a patients personal information or personal informed decision from unauthorised parties
As a midwifery student, what are the rules around Continuity of Care case notes?
- notes are owned by the student
- all information must be de-identified
- a code must be given in place of the woman’s name
Explain: Advocacy in midwifery
- midwives support women to advocate for themselves
- midwives advocate for women in circumstances typically outside the woman’s control. Eg their privacy during labor, personal information
What is the purpose of a healthcare record
is to provide a means of communication to facilitate the safe care and treatment of a patient
Documentation Policy
What information must appear on every page of a healthcare record
Medical record number
Family name and given name
Date of birth
Sex
Documentation Policy
Written documentation must be…
- clear and accurate
- legible and english
- use approved abbreviations
- written in dark ink
- time of entry (24hr clock)
- date of entry
- signed by author (inc. printed name and designation)
For student- docs must be co-signed by registered midwife
Documentation Policy
Documentation MUST…
- distinguished between what was observed/performed/ reported by other or is professional opinion
- made at the time of an event or as soon as possible afterwards. Time of writing must me distinguished from time of event
- sequential where lines form new entries must be written in the line below the previous to show the sequential nature of all entries
- errors must have a line put through them with written in error written next to it including the name, signature, designation and date of the author
Define: Autonomy
is a person’s ability to make or to exercise self-determining choice