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Informed consent

More than a signature

Documenting consent

Side view of male physician looking at on-screen test results

Corners of two file folders with file tabsIt is important to make notes in the patient's medical record about the consent discussion. The note might contain the following:

  • major risks discussed
  • minor but important risks mentioned
  • any questions the patient asked
  • answers given
  • the patient's apparent understanding (especially if it is a young person, or one whose mental capacity or competency might be questioned)
  • any handout materials provided to the patient

Print material, videos, or other handouts support the consent discussion but do not replace it.

What is the purpose of a consent form?

Close up of male hand signing consent form

  • A consent form itself is not the consent.
  • The dialogue with the patient is the key element of the consent process.
  • Follow hospital requirements, if applicable, for completing a consent form.

In many Canadian jurisdictions it is now a legal requirement that a consent form be completed before any surgical procedure is undertaken in a hospital. The consent form itself is an acknowledgement and serves as documentary evidence that the explanations were given and that the patient agreed to what was proposed.

In witnessing a signature, the witness simply confirms the identity of the patient who signed the document. The witness's role has no other legal significance.