The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy

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Audit tool: Consent

Details for quality assurance in consent can be found below. Please download the audit tool from the bottom of the page.

Part 1A: Data collection from patient records

There is evidence that the consent process includes consideration of

  • the service user’s age
  • capacity to consent
  • emotional state
  • cognitive ability 

The consent process includes discussion of treatment options, including

  • significant benefits
  • risks
  • side effects
  • alternatives to proposed intervention 

The consent process includes the opportunity for the service user to ask questions

The service user’s consent is documented before giving advice or beginning an assessment, examination, intervention, treatment or procedure

The service user’s consent is sought before sharing information to others directly involved in their care

The service user is informed of their right to decline physiotherapy at any stage

If the service user declined physiotherapy, this is recorded in the notes with the service user’s rationale for the decision if known

The service user is informed when their physiotherapy is observed or delivered by another healthcare professional/student

The service user has the opportunity to decline observation of their physiotherapy or treatment by another healthcare professional confidentially

Written information leaflets are used, where possible, to assist in the consent process

Where written information/ leaflets are used this is documented in the notes

Where consent is gained by the service user’s advocate under the relevant Mental Health or In/Capacity legislation, a record is retained in the service user’s records

 

Part 1B: Data collection from organisational policies and procedures

There are organisational policies for the consent process which include

  • Induction and training in the gaining of consent 

A procedure for the consent process to include

  • Discussion of treatment options, including significant benefits, risks side effects and alternatives to proposed intervention
  • opportunity for the service user to ask questions
  • establishing the service user’s consent or otherwise to sharing information to others directly involved in their care
  • informing the service user of their right to decline physiotherapy at any stage
  • specific recording in the notes when a service user declines physiotherapy, including a note as to the service user’s rationale for the decision if known
  • informing the service user that their physiotherapy may be observed or delivered by another healthcare professional/student
  • giving the service user the opportunity to decline observation of their physiotherapy or treatment by another healthcare professional confidentially
  • provision of patient information leaflets/sheets or other written information, where possible, to assist in the consent process
  • reference in the records where information leaflets are used

Identification of physiotherapy procedures where written consent is to be obtained

Storage of versions of written information/ leaflets in line with legislation for the retention of medical records

  • situations where the service user declines treatment by a student or support worker
  • procedures for safeguarding children
  • Procedures for safeguarding vulnerable adults 

Obtaining the service user’s consent before starting any examination/treatment/procedure

Organisational policies to include procedure for the consent process to include

  • Identifying when a service user may lack the capacity to give consent for treatment themselves
  • Situations where a formal assessment of capacity may need to be made by an appropriate practitioner
  • The process for invoking the relevant Mental Health or In/Capacity Act where a service user lacks the capacity to give consent for themselves
  • The process where consent is gained by the service user’s advocate under the relevant Mental Health or In/Capacity legislation, a record is retained in the service user’s records 
  • Where a valid Lasting Power of Attorney (LPOA) is in place its directions are followed
  • Where there is a valid advanced directive following its directions

There are organisational policies for delegation for the consent process which include

  • The induction and training of physiotherapy team members in the delegation of consent 

Indications for when it is appropriate to

delegate the gaining of consent

accept the delegated task of gaining patient consent

Part 2: Service user feedback

I was given the opportunity to

  • agree or disagree to the examination/ treatment/ procedure
  • discuss treatment options
  • ask questions
  • agree or disagree to my information being shared with others directly involved in their care
  • decline physiotherapy at any stage
  • agree or disagree to my treatment being observed by another healthcare professional/student
  • use written information, where possible, to help me in making decisions
  • discuss treatment being undertaken by another team member eg a student or support worker

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