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Thread: Recording of consent - what should be written in patient notes?

  1. #1
    Forum Member
    Join Date
    Nov 2016

    Recording of consent - what should be written in patient notes?

    Some colleagues and I were having a discussion about what is documented in patient notes when taking consent.

    My understanding was that it ought to be documented that PIS given, time to review, consent obtained.

    My colleagues felt that version numbers have to be written in patient notes. Whilst I accept that is good practice is that mandatory?

    Are there any MHRA guidance on specific points that HAVE to be written in the notes?

    I am only aware of the GMCs guidance on taking research consent (2013) which states on pg.12 to record 'key elements' of what was done in consent process. However there are no specifics of what should be documented in patient notes?

  2. #2
    Forum Member
    Join Date
    Oct 2020
    I wondered if anyone has thoughts of documenting consent on EHR/EPR systems. Many sites have moved to electronic documentation on Electronic Patient Record systems and many have the ability to make templates or checklists staff can complete to capture information, some also have the ability for "smart text and paragraphs" which can pre-populate text that is often required frequently for ease. Has anyone come across sites using pre-populated texts or checklists to document consent discussions to capture information and what is the opinion on this, as most consent discussions would then appear pretty identical for patients. However on the flip side but these prompt and fields that could be selected would capture information that is normally left out when relying on free text clinical annotations. What templates and extent of prompts would be acceptable, or should pre-populated templates and checklists be avoided?

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