Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals

SWBTB (2/10) 037 (b)
Appendix G2
Delegated Consent Approval Record
Name of Person taking
delegated consent
Procedure(s)
Consultant carrying out
procedure
Consultant method of
carrying out procedure
Risks / side effects
Benefits
Treatment options
Date practitioner approved to
take delegated consent
Date for Review of
Competency
Signature of Consultant who
will be carrying out
procedures/treatments
Signature of Health Care
Practitioner taking delegated
Consent
*Each healthcare professional taking delegated consent to have this delegated consent approval
record completed with the Consultant prior to undertaking delegated consent. A copy is to be kept
in the individual’s personal file and a copy sent to the Education Centre to be logged