Geriatric Quick Consult      Decision-making Capacity      Do #8

Document the consent

Knowledge

Action

Informed consent should always be documented in the medical record. It is wise to use a standard form that is written using language reviewed by health care attorneys. The form should specify the procedure, the alternatives (if any), which provider(s) will perform the procedure, and the potential risks, and it should be signed and dated. If the decisional capacity is impaired, this should likewise be documented, and consent should be obtained from a surrogate decision-maker.

Always document consent in the patient's medical record. Be as specific as possible. Obtain consent from the patient, or if impaired, a surrogate.