EPA 2C: Obtain Informed Consent
SCOPE OF WORK: This activity includes obtaining informed consent from patients, caregivers, and those with special needs for all interventions, tests, or procedures that graduates perform in clinical settings. Graduates must ensure that patients and caregivers understand the diagnoses, treatment options (or no treatment), and the costs, attendant risks, benefits, prognosis, expected outcomes and contingencies of each. Providers should NOT conduct the informed consent discussion for procedures or tests for which they do not know the indications, contraindications, alternatives, risks, and benefits.
- Professionalism and Ethics
- Person-Centered Care
- Critical Thinking and Decision Making
- Biomedical Science Application
- Elements of informed consent
- Criteria for patient’s legal competence
- Cultural awareness and sensitivity
- Oral health literacy and beliefs
- Strategies for effective communication in diverse populations (e.g., literacy and interpretation services)
- Required documentation specific to informed consent in electronic patient record (EPIC Wisdom)
- Obtain informed consent in a person-centered manner (includes active listening and shared decision making)
- Present treatment options to patient in accurate and understandable manner
- Apply effective communication strategies/techniques, including enlisting interpretation services if needed
- Educate patient so they have resources and agency to make informed health care decisions
- Give patient opportunity to ask questions; respond forthrightly to all patient questions
- Properly document informed consent, including important elements from the consent discussion in electronic patient record (Epic Wisdom)
| Obtain Informed Consent |
Meets Expectations of the Graduate
|
Progressing
|
Below Expectations
|
Critical Error
|
|---|---|---|---|---|
| Informed Consent Discussion | Fully explains diagnoses, all treatment options and attendant risks, benefits, costs, prognosis, expected outcomes and contingencies of each, using person-centered communication | Explains diagnoses and all the treatment options but omits one or two elements of information | Omits a feasible treatment plan option; omits key elements of information that may affect patient’s ability to choose their preferred treatment | Patient not given sufficient information to make a well- reasoned selection of which reasonable treatment option is preferred and in their best interests at this time |
| Documentation of Consent | Documents in detail patient consent, with signature, to the Plan of Care and the content of the consent conversation | Minor* omissions in documentation of patient consent to the Plan of Care and content of the consent conversation | Major** omissions in documentation of patient consent to the Plan of Care and content of the consent conversation | Documentation has errors of commission or omission that could lead to litigation; failure to obtain signature |
* Minor: did not document all contingencies or consequences discussed
**Major: failure to identify all treatment options presented and discussed
Rating on "Documentation" for this encounter will be included for the
assessment of this task.