The patient’s physician is encouraged, but not required to inform the patient who will be performing significant surgical during the patient’s operation and what each person will be doing. 2.3 Documenting Informed Consent The physician document in the patient’s medical record that a discussion was held that included discussion of all material information as described above, that the patient indicated understanding of the material information and informed consent was obtained. Informed consent may be documented in any of the following areas of the medical record: History and physical/Consultation Progress Note Pre-printed and approved informed consent formats Faxed copy from a physician’s office Special Circumstances in which a physician is not required to fully inform the patient: When the patient has requested that he/she not be so informed. (Thoroughly document this request in the medical record). Therapeutic Privilege Defined as whenever such disclosure would – likely result in serious harm rather than benefit the patient. In these instances the physician shall fully document in the medical record the facts that resulted in invoking therapeutic privileges. See Policy #113 Obtaining and Documenting”. “Consent, When an emergency procedure or operation is required, the physician must sign the Certificate of Emergency” on the consent form “Physician and in the progress notes the reason for the emergency procedures when consent cannot be obtained. 2.4 Physician orders The staff physician is responsible for orders for care prior to or promptly after admission. Verbal orders are discouraged. Telephone and/or verbal orders must be authenticated by the ordering physician within 48 hours. All entries in the medical record must be dated, timed and authenticated.
The patient’s physician is encouraged, but not required to inform the patient who will be performing significant surgical during the patient’s operation and what each person will be doing. 2.3 Documenting Informed Consent The physician document in the patient’s medical record that a discussion was held that included discussion of all material information as described above, that the patient indicated understanding of the material information and informed consent was obtained. Informed consent may be documented in any of the following areas of the medical record: History and physical/Consultation Progress Note Pre-printed and approved informed consent formats Faxed copy from a physician’s office Special Circumstances in which a physician is not required to fully inform the patient: When the patient has requested that he/she not be so informed. (Thoroughly document this request in the medical record). Therapeutic Privilege – Defined as whenever such disclosure would likely result in serious harm rather than benefit the patient. In these instances the physician shall fully document in the medical record the facts that resulted in invoking therapeutic privileges. See Policy #113 “Consent, Obtaining and Documenting”. When an emergency procedure or operation is required, the physician must sign the “Physician Certificate of Emergency” on the consent form and in the progress notes the reason for the emergency procedures when consent cannot be obtained. 2.4 Physician orders The staff physician is responsible for orders for care prior to or promptly after admission. Verbal orders are discouraged. Telephone and/or verbal orders must be authenticated by the ordering physician within 48 hours. All entries in the medical record must be dated, timed and authenticated.