Reason and Specific Benefits of the Directive or Delegation: Does establishing the directive or delegation address patients’ best interests? Yes No Unsure Comments: Authorizer: Does the authorizer: Have the scope, authority from their college, competencies and privileges Yes No Unsure (where applicable) to authorize performance? Have an established or anticipated professional relationship with the patient? Yes No Unsure Agree the directive applies to all his/her patients who meet the conditions? Yes No Unsure Have the ability to provide ongoing supervision directly, or are other Yes No Unsure provisions for appropriate supervision in place? Comments: Implementer: Does the implementer: Have the scope and authority from their own college (where applicable) to Yes No Unsure perform the procedure(s) Have the baseline competencies to perform the proposed procedure(s) and manage the outcomes given the: of the patient’s condition and needs, of the procedure and its outcomes, and circumstances in the situation including resources and safeguards Yes No Unsure (such as established standards of practice, written materials, back-up and supervision), and opportunities to attain and maintain competence? Comments: Consent: Can informed consent be properly obtained? Yes No Unsure Comments: Review and Quality Monitoring Processes: Is there a process in place to ensure a regular review of the directive or Yes No Unsure delegation?
Reason and Specific Benefits of the Directive or Delegation: Does establishing the directive or delegation address patients’ best interests? Yes No Unsure Comments: Authorizer: Does the authorizer: Have the scope, authority from their college, competencies and privileges (where applicable) to authorize performance? Yes No Unsure Have an established or anticipated professional relationship with the patient? Yes No Unsure Agree the directive applies to all his/her patients who meet the conditions? Yes No Unsure Have the ability to provide ongoing supervision directly, or are other provisions for appropriate supervision in place? Yes No Unsure Comments: Implementer: Does the implementer: Have the scope and authority from their own college (where applicable) to perform the procedure(s) Yes No Unsure Have the baseline competencies to perform the proposed procedure(s) and manage the outcomes given the: of the patient’s condition and needs, of the procedure and its outcomes, and circumstances in the situation including resources and safeguards (such as established standards of practice, written materials, back-up and supervision), and opportunities to attain and maintain competence? Yes No Unsure Comments: Consent: Can informed consent be properly obtained? Yes No Unsure Comments: Review and Quality Monitoring Processes: Is there a process in place to ensure a regular review of the directive or delegation? Yes No Unsure
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