Consent to Examination or Treatment Policy - Nottinghamshire ...

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Consent to Examination or Treatment – 1.03 7.9 The standard consent forms (1, 2 and 3) should never be used for adult patients unable to consent for themselves. For more minor interventions, this information should be entered in the patient’s notes. 8.0 PROCESS FOR IDENTIFYING STAFF CAPABLE OF PERFORMING THE PROCEDURE AND AUTHORISED TO OBTAIN CONSENT FOR THE PROCEDURE 8.1 During the period of induction new staff will be mentored to ensure that where this falls within the scope of their role and is necessary e.g. to maintain sufficient numbers of staff with this competence to provide reasonable coverage they are competent to both gain informed consent and/ or to perform specific procedures. Once the Line Manager has been assured that competency has been achieved the staff member can practice without supervision. The Manager of the Clinical Team is responsible for ensuring that there are sufficient staff trained / competent to obtain consent, even if they are not authorised to perform the procedure for which the consent has been gained. They are also responsible for monitoring the practice of these staff to ensure practice remains at the required level. In the main this will be achieved through clinical supervision processes but at least annually there will need to be a more formal , recorded review to confirm competency has been maintained e.g. as part of the PAD process. 8.2 Existing staff who currently obtain consent and perform procedures do not require an additional appraisal following the introduction of this policy unless their annual review is due. They remain responsible for their decisions and actions. The Line Manager is responsible for maintaining records of those staff who are not competent to obtain consent and carry out specific procedures and for identifying when formal reviews will be undertaken . 8.3 Clinical Directors and General Managers are responsible for maintaining a record of staff in relation to consent. This can be delegated to specific others at the operational level but there must always be a single record, updated as necessary for the service. This record will maintain as a minimum, the following information: • Staff member’s name, job title and place of work • A list of procedures for which the staff member has been assessed as being competent to obtain consent • A list of procedures for which the staff member has been assessed as being competent to obtain consent and to perform the procedure • Details of the specific training undertaken 9.0 PROCESS FOR THE DELIVERY OF PROCEDURE SPECIFIC TRAINING ON CONSENT, FOR CLINICAL STAFF WHO ARE NOT CAPABLE OF PERFORMING THE PROCEDURE, BUT WHO ARE AUTHORISED TO OBTAIN CONSENT FOR THAT PROCEDURE 9.1 The Line Manager is responsible for ensuring that records are maintained. Appropriate training and supervision is given to staff who are authorised to obtain informed consent even though they must be required to be competent to undertake the procedure for which consent is sought. 9.2 Training on the specifics of obtaining appropriate informed consent in undertaking procedures must be provided by staff trained and competent in the procedures where consent will be sought). Training must cover the following issues:- • Defining consent and consideration of the principles of the Mental Capacity Act 2005. • The detail of the procedure to be undertaken. • The risks and benefits of that procedure, along with alternatives to the procedure. • Common questions asked by more junior staff and patients in relation to the procedure. ISSUE 6 – AUGUST 2012 7
ISSUE 6 – AUGUST 2012 8 Consent to Examination or Treatment – 1.03 9.3 Staff must be re-assessed annually as part of the PAD process or more frequently if considered necessary by their Line Manager to ensure standards are maintained in relation to obtaining consent and for undertaking procedures. 10.0 PROCESS FOR FOLLOWING UP WHERE AN INDIVIDUAL HAS OBTAINED CONSENT WITHOUT THE AUTHORISATION TO DO SO 10.1 Members of staff who obtain consent without the authorisation to do so will be the subject of a Conduct Investigation and action taken as necessary. If the breach is of sufficient severity the professional organisation for that staff member could be informed. They would then determine whether any further action is warranted. 10.2 All such instances must be reported through the Trust Incident Reporting System (Safeguard) and an incident form completed. The circumstances of the breach will determine whether or not this should be reported as a serious incident. 11.0 SEEKING CONSENT 11.1 When a patient formally gives their consent to a particular intervention, this is only the endpoint of the consent process. It is helpful to see the whole process of information provision, discussion and decision-making as part of ‘seeking consent’. This process may take place at one time, or over a series of meetings and discussions, depending on the seriousness of what is proposed and the urgency of the patient’s condition. 11.2 Single stage process: In many cases, it will be appropriate for a health professional to initiate a procedure immediately after discussing it with the patient. For example, during an ongoing episode of care a physiotherapist may suggest a particular manipulative technique and explain how it might help the patient’s condition and whether there are any significant risks. If the patient is willing for the technique to be used, they will then give their consent and the procedure can go ahead immediately. In many such cases, consent will be given orally. The consent process must always be recorded either by the use of the Consent Form or an entry into patient’s healthcare record. 11.3 If a proposed procedure carries significant risks, written consent must be sought and an entry made in the patient’s healthcare record, health professionals must take into consideration whether the patient has had sufficient chance to absorb the information necessary for them to make their decision. As long as it is clear that the patient understands and consents, the health professional may then proceed. 11.4 Two or more stage process: - In most cases where written consent is being sought, treatment options will generally be discussed well in advance of the actual procedure being carried out. This may be on just one occasion (either within primary care or in a hospital outpatient clinic), or it might be over a whole series of consultations with a number of different health professionals. The consent process will therefore have at least two stages: the first being the provision of information, discussion of options and initial (oral) decision, and the second being confirmation that the patient still wants to go ahead. The consent form must be used as a means of documenting the information stage(s), as well as the confirmation stage, and an entry made in the patient’s healthcare record. 11.5 Patients receiving elective treatment or investigations for which written consent is appropriate should be familiar with the contents of their consent form before they arrive for the actual procedure, and should have received a copy of the page documenting the decision-making process. They may be invited to sign the form, confirming that they wish treatment to go ahead, at any appropriate point before the procedure: i.e. in out-patients, at a pre-admission clinic, or when they arrive for treatment. If a form is signed before patients arrive for treatment, however, a member of the healthcare team must check with the patient at this point whether they have any further concerns and whether their condition has changed. This is particularly important where:
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Consent to Examination or Treatment Policy - Nottinghamshire ...

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