Complete Your CE Test Online - Click Here In addition to being an ethical obligation of caregivers, legislation in all 50 states requires that clients be informed of all important aspects of a treatment and/or procedures, although the details of these laws and statutes differ greatly. General guidelines require clients to be informed of the nature of their condition and the proposed treatment or procedure, its purpose, risks and benefits and their probability, risks and benefits of alternatives, and risks and benefits of not receiving the treatment. Failure to obtain adequate informed consent renders a health care professional liable for negligence or battery and constitutes medical malpractice. While informed consent is a well-established practice, it often fails to meet its stated purpose. Recent research findings strongly suggest that procedures to obtain informed consent may not adequately promote the patient’s comprehension of the information provided, rendering the consent not truly “informed.” Studies suggest that a majority of patients do not read a consent form before signing it, and less than half of the U.S. population understands commonly used medical terms. Additionally, clients with limited reading ability are at increased risk for medical errors, due to problems reading medication bottles, appointment slips, self-care instructions, and health education brochures. These clients are also likely to have trouble reading materials intended to aid in obtaining informed consent. Several methods of improving the procedures of obtaining informed consent have been proposed, including improving the readability of consent forms, asking clients for recall to establish understanding, adding additional stimuli, such as multimedia presentations and providing written information. The following section discusses “best practices” for informed consent forms, but also applies to other written material intended for the client. In order to ensure that clients understand the procedure to which they are consenting, it is important that all materials be presented in a comprehensible manner. Written health care materials, such as consent forms, are often written with a relatively complex sentence structure and vocabulary, making it difficult for the average adult to interpret the information. In addition, providing these materials in the language the client finds most familiar is likely to increase comprehension substantially for many individuals. Providing written information to clients regarding their diagnoses, proposed treatments, and other information given during informed consent discussion allows the patient to refer back to such information, which promotes comprehension. Some investigators have proposed that clients should receive written consent forms days before receiving a procedure. Informed consent is always specific: The goal of the informed consent process is to ensure that clients have an opportunity to be informed participants in decisions about their health care. To achieve that goal, practitioners must explain the patient’s condition and inform the patient about treatment options and alternatives, including the risks and benefits of each, providing the information that a “reasonable person” in similar circumstances would want to know in making the treatment decision. A key element of the process is that the practitioner explains why he or she believes recommended treatments or procedures will be more beneficial than alternatives in the context of the patient’s diagnosis. Thus informed consent is always specific: to the individual patient, the clinical situation, and the recommended plan of care or recommended treatment(s) or procedure(s). Consent for multiple treatments: However, to say that consent is always specific is not the same as saying that separate consent is always required for every episode of repeated treatment. When the plan of care for a given diagnosis involves repeated treatments or procedures, practitioners should ensure the patient understands that he or she is consenting to multiple episodes of treatment. Separate consent is not required for each individual episode. If a patient’s condition changes enough to warrant a change in the plan of care, the practitioner must explain to the patient how the situation has changed, establish goals of care in light of the new situation, recommend a new plan of care, and obtain informed consent for the new plan or for specific treatment(s) or procedure(s) now recommended. Notification versus consent: Informed consent is also different from “notification,” that is, providing general information relevant to clients’ participation in health care. Similarly, every patient entering a health care facility must be notified that his or her records will be used for purposes of routine health care operations. Likewise, each patient should be notified that his or her information may be used for quality improvement purposes to enable the organization to fulfill its obligation to monitor the quality of care it delivers and to carry out quality improvement activities for the benefit of all clients. Notification informs clients not only about their rights, but also about organizational activities and processes that shape how care is delivered. Like informed consent, notification serves the goal of respecting clients as moral agents14 . Informed consent should: ● ● Explain the patient’s condition and diagnosis clearly and concisely, in language he or she can understand. ● ● Inform the patient about the treatment(s) or procedure(s) you recommend, including: ○ ○ The name, nature, and details of the recommended treatment(s) or procedure(s). ○ ○ Indications for the recommended course of action. ○ ○ Likelihood of success of the recommended treatment(s) or procedure(s) for this patient. ● ● Describe the expected benefits and known risks of the recommended treatment(s) or procedure(s). ● ● Describe reasonable alternatives to the recommended treatment(s) or procedure(s), including the expected benefits and known risks of each alternative. ● ● Identify the practitioners who will be involved in performing the treatment or procedure. ● ● Advise the patient if the recommended treatment or procedure is novel or unorthodox. ● ● Encourage the patient to ask questions. Intake interview and documentation Clients should fill out a formal intake form on their first visit that should include: ● ● Client’s name, address, and telephone or other contact number(s). ● ● Reason for visit. ● ● Medical history. ● ● Insurance/payment methods (if applicable). ● ● Person to call in case of emergency, with their contact information. The client should also sign and date the following statements: ● ● Release of medical records. ● ● Notice of informed consent with scope and limitations of practice. ● ● Client’s Bill of Rights. A Client’s Bill of Rights typically includes the following information: ● ● Name of practitioner. ● ● Details of practitioner certification and list of credentials. ● ● Practitioner’s area of expertise, philosophy, and/or approach to massage. ● ● Fees and service schedule. ● ● Payment terms. ● ● Filing procedures for written complaints. ● ● A right to information statement, asserting the client’s right to the following information: ○ ○ Practitioner’s assessment of the client’s physical condition. ○ ○ Recommended treatment, estimated duration of treatment, and expected results. ○ ○ Copy of client’s health forms/records held by practitioner. ● ● Statement of confidentiality. ● ● Statement of refusal, explaining the client’s right to terminate a course of treatment at any time and choose a new practitioner. ● ● Clients’ right to invoke, explaining client’s right to invoke these rights without fear of reprisal. Both the practitioner and client are ensured the “right of refusal.” For a client, this means the right to refuse, modify, or terminate treatment Massage.EliteCME.com Page 3