THE CHAMBERSBURG HOSPITAL

 Subject: Article X; Consent: Surgical/Invasive Procedures,
 Administration of Anesthesia, Administration of Blood, Blood Products               Original Date: 8/01/1993
 and Transfusion

 Department: Medical Staff
                                                                                     Revision Date(s): 5/23/2006¸
 Area:                                        Discipline:

 Classification:         Medical Staff Rules and Regulations                         Review Cycle: Annually

              10.1              POLICY STATEMENT:

              All patients having surgery, certain invasive procedures/treatment, sedation, or anesthesia resulting in a

loss of protective reflexes, or administration of blood or blood products are required to sign the appropriate

Chambersburg Hospital Consent Form. The practitioner responsible for performing the procedure or administering

the medication must explain the procedure he/she is to perform, the risks, benefits, complications, and alternatives

of the planned procedure to the patient or the patient’s legal representative.

              The practitioner documenting this explanation must make a notation in the medical record. Hospital

personnel may explain the preparation necessary for the procedure and reinforce the practitioner’s explanation. If

the patient asks specific questions about the procedure, staff shall notify the practitioner to discuss the questions

directly with the patient.

              Persons authorized to give consent:

              1.     Self: if 18 years of age or older.

              2.     Parent: if patient is not of legal age and is single. If parents are deceased, the oldest brother or

sister of legal age or legal guardian.

              3.     If patient unable to sign due to mental/physical impairment, the following may sign in this order:

                     *          Court appointed guardian.

                     *          Spouse.

                     *          Oldest son/daughter of legal age if spouse deceased or if divorced.

                     *          Parents, if patient is unmarried.

              4.     Minors as defined in Consent by Minors below.

              5.     A legal guardian may give consent.

              6.     A medical power of attorney may give consent.

                a.   A financial power of attorney MAY NOT give consent.

                b.   If there is no legal guardian or medical power of attorney, notify the hospital’s Social Services

Department or the Office of the Aging.

                c.   If staff cannot reach the medical power of attorney after multiple attempts, and the surgeon deems

surgery is necessary to prevent loss of life or limb, two (2) physicians must document that procedure is necessary and

attest to that in the medical record.

                When necessary, the employee may fill in the blank space for the procedure on the Consent Form, as

noted on the Physician Order Sheet. Employees cannot indicate any other information on the consent form, that the

responsible practitioner must complete information. Note: Abbreviations for “right” and “left” are not accepted

on consents. The staff and the patient are to sign the consent form, including date and time.

                Hospital personnel are responsible for assuring:

                1.   The patient, or other authorized individual giving consent, read and understood the form.

                2.   The patient, or other authorized person giving consent, has all of his or her questions answered.

                3.   The patient, or other authorized individual giving consent, has in fact signed the form.

                4.   Another signed consent is obtained if “No” has been changed to “Yes.” (Must be a clean “Yes” -

no initials).

                The Hospital will not carry out any surgery or procedure covered by this policy on any patient

who refuses to consent.

                The Hospital recognizes that an adult of sound mind has the right to refuse treatment. Staff is to

complete a Refusal to Consent to Procedure or Refusal to Permit Blood Transfusion form when refusal occurs.

                In the case of a minor when the parent or legal guardian is refusing treatment for the minor, staff should

notify the attending practitioner immediately.

                No consent is necessary to treat or perform procedures on a patient with a life-threatening emergency.

                     10.2         DURATION OF CONSENT:

          An informed consent has continuing force for sixty (60) days, unless the patient revokes the consent before

the sixty (60) days, and/or there is a change in the patient’s physical/mental status.

                     10.3         SPECIAL CIRCUMSTANCES:

                Anemia or Gastrointestinal Bleeding

                When treating or admitting patients whose diagnosis is anemia or gastrointestinal bleed, staff will do

the following:
              1.     Put Form P09049 (Authorization for Blood Transfusion) on the patient’s chart at the time


              2.     In nonemergent situations, ensure that Form P09049 (Authorization for Blood Transfusion) is

                     complete (signed by both patient and practitioner) before administering the blood or blood


             Consent by Minors:

             Staff should secure consent by the minor’s parent or other person standing “in loco parentis” (minor’s

natural guardian).

             Pennsylvania Statutory Law has the following provisions that apply to consent for minors:

             1.      A minor who suffers from the use of a controlled or harmful substance may give consent to the

furnishing of medical care or counseling relating to diagnosis or treatment.

             2.      Any person who is 18 years of age or older, or has graduated from high school, or has married or

has been pregnant, may give effective consent to medical, dental and health services for himself or herself, and the

consent of no other person shall be necessary.

             3.      Any minor who has been married or who has borne a child may give effective consent to medical,

             dental and health services for his or her child.

             4.      Any minor may give consent for medical and health services to determine the presence of or to

treat pregnancy and venereal disease, and the consent of no other person is necessary.

             5.      Medical, dental and health services may be rendered to minors of any age without the consent of a

parent or legal guardian when, in the practitioner’s judgment, an attempt to secure consent would result in delay of

treatment which would increase the risk of the minor’s life or health.

              6. Where the parents of a minor are not married (either by divorce or separation), either parent may

give a valid consent. Where a court has awarded custody to one or the parents, the custodial parent’s consent, or

refusal shall govern in the event of a dispute over the matter between the parents. If the custodial parent is

unavailable to give consent, staff may obtain consent from the non-custodial parent.

             Consent for Vaginal Delivery Performed by a Certified Nurse Midwife:

When a certified nurse midwife is to perform a vaginal delivery, the certified nurse midwife may explain the risks,

complications, alternatives, and staff will use the Consent for Surgery/Invasive Procedure Form P09364. The

certified nurse mid-wife may also answer questions regarding the procedure.

             Consent Via Telephone:

             When verbal consent for Emergent treatment and/or procedure must be obtained by telephone from
family members or other authorized person, two staff members, preferably practitioner and/or R.N. must listen to the

telephone conversation and sign the proper form in the space provided for signature of witness.

              Note:         Verbal or telephone consent should NOT be accepted for SCHEDULED procedure,

treatment or surgery. The patient should sign the consent in advance.

If it is necessary to utilize verbal or telephone consent for scheduled procedure, treatment or surgery, the

circumstances surrounding this need must be documented on the nurses’ and/or practitioner progress notes.

              Electroconvulsive Therapy (ECT

Consent for ECT, and consent for anesthesia given for ECT, is valid only if obtained directly from the patient or by

court order. Guardian or power of attorney (including durable power of attorney) may not consent for ECT or for

anesthesia given for ECT.

              South Mountain Restoration Center residents:

              If South Mountain Restoration Center produces a consent form signed by the next of kin, a legal

guardian, or the South Mountain Administrator, staff should presume that the patient is not capable of giving


              If a patient from South Mountain presents with no consent form, staff should call the South Mountain

Administrator pursuant to their policy and have them make a determination. If the patient signs the consent form, the

attending practitioner has to determine if this patient is competent to make medical decisions before the Hospital will

accept the consent form.

              Unconscious Patient:

              In the event transport brings an unaccompanied, unconscious patient to The Chambersburg Hospital,

and the attending practitioner feels a surgical or invasive procedure is necessary to prevent death or impairment of a

body function, no consent is necessary.


              1.   An “X” or other mark is acceptable if patient is capable of giving consent.

              2.   If the patient has checked, “No," on any area of the consent, the Practitioner must be notified. A

conversation between the practitioner and the patient must occur.

              3.   If the consent is signed with no witnesses, ascertain from the patient that it is indeed their

signature, and then have the patient initial under the witness line that you have signed.

              4.   If the consent arrives with no date and/or time, write the current date and/or time in the space

provided and have the patient initial near the date and time space.

              5.   Copies of consents are acceptable as long as they meet all of the requirements noted in this article.
              6.   The Hospital may use the same consent form for a series of the same procedure providing:

              a.   At the time the practitioner obtains the informed consent and the patient signs it, the practitioner

informs the patient that there is a series of this procedure planned.

              b.   The patient’s condition and/or the risks do not change significantly.

              c.   In the “Describe the Procedure” space, either the number planned (e.g. esophageal dilatation X 4),

or document that the practitioner is to determine the number must be present.

              7.   See Forms Manual for guidelines for completing related form:

                   P02500 - Refusal to Permit Blood Transfusion

                   P09049 - Authorization for Blood Transfusion

                   P09050 - Consent for Administration of Anesthesia

                   P09051 - Consent for Surgery/Invasive Procedure

                   P02505 - Refusal to Consent to Procedure

                   P09364 - Consent for Surgery/Invasive Procedure (Midwife).

To top