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					    SUBJECT:             INFORMED CONSENT                                    REFERENCE #1003
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    DEPARTMENT:                                                                OF: 5
    IMAGING
    SERVICES
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POLICY:

●         It is the policy of __________________ Hospital that all inpatient and outpatient medical
          records must contain a properly executed and completed written informed consent form for
          all procedures and treatments specified by the hospital’s medical staff, and state or federal
          laws/regulations.

●         Informed consent must be obtained from the patient, or the patient’s legal guardian, by the
          anesthesiologist prior to the administration of anesthesia and by the performing practitioner
          prior to the performance of operative and/or invasive procedures, diagnostic or therapeutic
          procedures, or situations when it is deemed advisable to have formal documentation of the
          patient's consent for treatment.

●         Written verification of the informed consent must be on the patient's medical record prior to
          initiation of anesthesia or any of the above stated procedures.

PROCEDURE:

●         A properly executed informed consent form contains at least the following:

          ●     Name of the patient and, when appropriate, the patient’s legal guardian

          ●     Name of the hospital

          ●     Name of the specific procedure

          ●     Name of the practitioner(s) performing the procedure(s) or important aspects of the
                procedures, as well as the name(s) and specific significant surgical tasks that will be
                conducted by practitioners other than the primary surgeon/practitioner

                ●      Significant surgical tasks include harvesting grafts, dissecting tissue,
                       removing tissue, implanting devices, altering tissues

          ●     The risks, drawbacks, complications, side effects and expected benefits or effects of
                anesthesia and/or procedures, treatments and therapies

          ●     The likelihood of achieving goals

Imaging
    SUBJECT:            INFORMED CONSENT                                      REFERENCE #1003
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    DEPARTMENT:                                                                 OF: 5
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          ●     Potential problems related to recuperation

          ●     Alternative choices of and to anesthesia and/or procedures, treatments or therapies
                including risks, drawbacks, complications, side effects and expected benefits of
                alternative treatments/therapies

          ●     The risks, drawbacks and complications, side effects and expected benefits or
                effects of receiving no treatment/therapies

          ●     The anesthesiologist’s/performing practitioner’s statement that the procedure was
                explained to the patient and/or legal guardian

          ●     The following signatures are required as part of the informed consent:

                ●      Patient or legal guardian

                ●      Professional individual witnessing the consent

                ●      The anesthesiologist and/or performing practitioner who explained the
                       procedure to the patient and/or legal guardian

          ●     Date and time consent is obtained

●         Obtaining Informed Consent:

          ●     It is the anesthesiologist and/or performing practitioner's responsibility to obtain the
                informed consent.

          ●     Hospital personnel cannot be involved in providing information that is necessary for
                informed consent. Only the performing practitioner and/or anesthesiologist can
                provide the information.

          ●     The informed consent form is:

                ●      Completed and discussed with the patient and/or legal guardian by the
                       anesthesiologist and/or performing practitioner

                ●      Supplemented with verbal discussion
Imaging
   SUBJECT:           INFORMED CONSENT                                      REFERENCE #1003
                                                                            PAGE: 3
   DEPARTMENT:                                                                OF: 5
   IMAGING
   SERVICES
                                                                            EFFECTIVE:
   APPROVED                                                                 REVISED:
   BY:



              ●      Supplemented through written additions that give further relevant information

          ●   Medical information set forth needs to be written in clear, simple and easily
              understood terms.

          ●   Documentation must clearly in
				
DOCUMENT INFO
Description: consent forms with an informed consent to treat the patient
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