Informed Consent Note (Procedure/Anesthesia)

Date/Time of Consent Discussion: [Date and time of consent discussion]

Location: [Clinic / ED / Pre-op / Inpatient unit / Other]

Planned Procedure Date: [Scheduled date/time]

Service(s): [Primary surgical/procedural service]; [Anesthesia service if separate]

Participants

• Patient: [Present and participating / Unable to participate: reason]
• Clinician(s) obtaining consent: [Name, role – surgical/procedural]; [Name, role – anesthesia if different]
• Interpreter: [Name/ID], [language], [in-person / video / phone] (Include only if used)
• Decision-maker if not patient: [Name], [relationship], [authority basis: healthcare proxy / legal guardian / next of kin / court-appointed]
• Witness: [Name and role] (Include only if required by facility policy)
• Family/support persons: [Names and relationship] (Include only if they participated meaningfully)

Decision-Maker Assessment

Capacity: [Patient demonstrated decision-making capacity / Patient lacked capacity due to reason; surrogate name, relationship consented on their behalf / Emergency exception invoked: rationale]

Voluntariness: [Consent given freely without coercion / Concerns noted: description]

Sedation status: [Consent obtained before any sedating or amnestic medications / No sedating medications planned prior to consent / Consent obtained after sedation: rationale and capacity assessment]

Procedure(s) Consented

Indication: [Working diagnosis and clinical rationale]

• Procedure: [Full procedure name]

  • Site/laterality/level: [Specification] (Include if applicable)
  • Approach/technique: [e.g., laparoscopic, open, robotic] (Include if material to consent)
  • Anticipated devices/implants: [Description] (Include if relevant)
  • Contingencies discussed: [e.g., conversion to open, additional biopsy, transfusion] (Include only those explicitly discussed)

(Add additional procedure entries as needed)

Anesthesia Plan

• Anesthesia type: [Local / Moderate sedation / Deep sedation / General / Regional / Neuraxial / Combined]
• Regional/neuraxial technique: [Block type, laterality/level] (Include if applicable)
• Invasive monitoring: [Arterial line / Central line / Other] (Include if applicable)

(If anesthesia consent documented separately: "Anesthesia consent obtained separately; see anesthesia consent documentation.")

Risks, Benefits, and Alternatives

(Document what was actually discussed; prioritize procedure-specific and anesthesia-specific risks that are common or severe, and any risks increased by patient comorbidities.)

• Benefits discussed: [Intended benefits and expected outcomes]
• Material risks discussed – procedure: [Key procedure-specific risks]
• Material risks discussed – anesthesia: [Key anesthesia-specific risks]
• Patient-specific risk modifiers: [Risks increased by comorbidities] (Include if applicable)
• Alternatives discussed: [No treatment/watchful waiting]; [Alternative approaches if discussed]; [Rationale if only one option clinically appropriate]

Personnel and Learners

(Include this section only if learners will participate or sensitive educational exams are applicable; otherwise omit entirely.)

• Learner participation: [Trainee involvement disclosed]; Patient [authorizes / declines] learner participation in procedural tasks.
• Sensitive examinations for educational purposes: Patient [authorizes / declines] [breast / pelvic / prostate / rectal] examination by [who may perform] while anesthetized.

Patient Understanding and Decision

Understanding: [Questions asked and answered / Teach-back used / Interpreter confirmed understanding / Questions invited, patient had opportunity to ask and expressed no further questions] (Do not claim understanding unless actually assessed.)

Decision: Patient [consents to proceed / declines / defers decision].

Limitations on consent: [e.g., declines blood products, limits trainee participation] (Include only if applicable)

Patient informed of right to withdraw consent at any time.

Documentation

• Consent form status: [Signed consent completed / Verbal consent documented: reason]
• Form location: [Scanned to EHR / Paper chart / Electronic signature / Signed consent verified, pending scan]
• Signature date/time: [Date and time]
• Witness: [Name and role] (Include if required by policy)