Informed Consent Discussion Note (Procedure/Treatment)

Date/Time of Discussion: [Date and time]

Setting: [clinic / inpatient / ED / telehealth]

Procedure/Treatment: [Full name; laterality/site if applicable]

Urgency: [elective / urgent / emergent]

Clinician Conducting Discussion: [Name and role/title]

Related Consent Forms: [Reference to signed consent forms in chart with date/time and chart location, or "none required"]

Participants & Capacity

(Explicitly document each item; do not infer.)

• Participants present: [Patient; names/roles of others present]
• Interpreter needed: [yes / no] (If yes, include language, modality, and interpreter ID if required.)
• Decision-making capacity for this decision: [yes / no]
• Legal decision-maker: [Name; relationship; authority basis] (Only include if capacity impaired or patient is a minor.)

Clinical Indication

[Working diagnosis and relevant clinical context. Rationale for recommending this intervention now. Expected course without treatment.] (2–4 sentences.)

Discussion Summary

(Document what was actually discussed. Tailor content to the individual; avoid generic boilerplate. Omit items that do not apply.)

• Nature and purpose of intervention: [Plain-language description]
• Anesthesia/sedation plan: [Type and plan] (Only include if applicable.)
• Expected benefits: [Patient-specific benefits aligned with patient goals]
• Material risks discussed: [Common risks; serious-though-rare risks relevant to this patient]
• Reasonable alternatives: [Alternatives including watchful waiting or no treatment]
• Trainee participation: [Scope of trainee involvement] (Only include if discussed per institutional policy.)

Understanding & Decision

• Questions: [Questions asked and responses summarized, or "no questions asked"]
• Assessment of understanding: [Teach-back summary—patient/surrogate restated key points in own words, or other specific evidence of comprehension] (Avoid conclusory statements like "patient understands.")
• Decision: [consents to proceed / declines / defers decision / conditional consent with conditions specified]
• Consent documentation: [Written consent signed with chart location / Verbal consent documented with reason written not required]
• If declined or deferred: [Risks of refusal explained; alternative plan] (Only include if applicable.)