If you are a patient presenting for a routine health care service, for example general medical, paediatric, family planning, obstetric, Immunization, STD, TB, and/or HIV clinic services, then you will asked to fill up a general consent form to be completed prior to any of these services being rendered. This is not informed surgical or invasive procedure consent form.
Image credit : Tung Shin Hospital, Kuala Lumpur, Malaysia <http://www.tungshin.com.my/useful-info/admission-discharge/>
The general consent is usually obtained when the patient is admitted as an inpatient to the hospital or when the patient is registered for the first time as an outpatient. However in the U.S., the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule “permits, but does not require, a covered entity voluntarily to obtain patient consent for uses and disclosures of protected health information for treatment, payment, and health care operations. Covered entities that do so have complete discretion to design a process that best suits their needs.”
Patients are given information on the scope and limits of the general consent, such as which tests and treatments are included under the general consent. Patients are also given information about those tests and treatments for which a separate informed consent will be obtained.
The hospital defines how a general consent is documented in the patient’s medical record, for example the general consent to treatment may be located by a Health Information Management (HIM) / Medical Records (MR) practitioner.to be found on the reverse of the face sheet (or admission/discharge record).
General consent forms are also used at teaching hospitals and patients are advised that doctors, nurses and other healthcare professionals in training will be involved in the patient’s care and treatment.
A general consent usually contains information as follows:
- a general consent form authorises the attending doctor, other doctors and healthcare professionals who may be involved in a patient’s care, to provide a diagnosis, care and treatment considered necessary or advisable by the doctor(s)
- the general consent form does not guarantee the patient about the result of his or her examination or treatment at the hospital
- the general consent notes if it is likely that students and other trainees will participate in care processes
- provisions in the general consent form inform patients that their decision to seek care from a hospital is not based upon any understanding, representation or advertisement that the doctors treating them are employees, agents or apparent agents of the hospital, and that they also understand that they have the opportunity to request that their own doctor participate during in their care at the hospital
- the general consent form may also authorise a hospital to examine, use, store and dispose of any tissue, fluids or specimens removed from a patient’s body during his or her outpatient visit or hospital stay
Agreeing to a general consent for treatment by a patient before admission as an inpatient or been registered for the first time as an outpatient, may apply at any (Malaysian) hospital setting. However, hospitals that are Joint Commission International (JCI) accredited or seeking JCI accreditation status or re-applying for JCI accreditation status need to comply with the JCI Standard PFR6.3 which implies that “General consent , is clear in its scope and limits.” The medical record must contain a copy of the general consent in any hospital setting.
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
U.S. Department of Health & Human Services, What is the difference between “consent” and “authorization” under the HIPAA Privacy Rule?, viewed 4 September 2012 < http://www.hhs.gov/hipaafaq/use/264.html>
