Student Informed Consent Note (Supervised)

Note Type: Student Informed Consent Note (Supervised)

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

Setting: [in-person / telehealth-video / telehealth-phone / inpatient / outpatient clinic / ED / OR / bedside / other]

Procedure/Intervention: [Plain-language description; clinical/procedural name; laterality/site as applicable]

Sedation/Anesthesia: [None / Minimal / Moderate / Deep / General / Neuraxial]

Sensitive or Training-Related Exam: [Yes / No] (If yes, specify exam type and whether under sedation/anesthesia.)

Scheduled Procedure Date/Time: [Scheduled date/time / immediate / urgent]

Participants:

• Patient Present: [Yes / No] (If no, identify surrogate and reason.)
• Student Clinician: [Name], [Role], [Service/Department]
• Supervising Clinician(s): [Name(s)], [Role(s)], [in-person / remote], [Timing relative to discussion]
• Interpreter: [Not required / In-person / Phone / Video], [Language] (If needed but unavailable, document reason and mitigation.)
• Chaperone: [Not applicable / Present: name and role / Patient declined] (Include for sensitive exams.)

(If information is unavailable, document "Unknown at time of note" with plan to clarify. Do not infer capacity, consent, interpreter use, or learner disclosures—explicitly document each.)

Clinical Indication

[Working diagnosis/condition prompting the procedure, why recommended now, and patient-specific factors influencing risk/benefit.] (2–5 sentences.)

Consent Discussion

Nature and Purpose: [What the procedure entails, where it will occur, intended purpose/goals, and key steps if relevant to understanding.]

Expected Benefits: [Anticipated benefits and goals; acknowledge uncertainty or range of outcomes when applicable.]

Material Risks:

• [Common risks with meaningful impact]
• [Rare but serious risks]
• [Sedation/anesthesia-related risks and post-anesthesia expectations] (Include only if sedation/anesthesia planned.)

Reasonable Alternatives:

• [Alternative procedures with brief risks/benefits]
• [Medical management/non-procedural options]
• [Watchful waiting/observation]
• [No treatment: expected consequences of declining]

Learner Involvement Disclosure: [Tasks learners may perform; supervision model; disclosure for sensitive/intimate exams especially under sedation.] Patient/surrogate [accepted / declined] learner participation. (Omit if not applicable.)

Questions and Understanding: [Questions asked and answers provided.] [Confirmation of understanding via teach-back or explicit statement.] Patient/surrogate confirmed decision is voluntary and understands right to refuse or withdraw consent.

Capacity and Decision

Capacity: [Patient demonstrates decision-making capacity: Yes / No / Uncertain] (If impaired or uncertain, document basis and escalation. If lacking capacity, document surrogate name, relationship, basis of authority, and participation. If emergency exception, document emergent nature and policy pathway.)

Decision: [Consent given / Refused / Deferred / Withdrawn] (Note any scope limitations or conditions. If refused or deferred, document alternative plan.)

Written Consent Form: [Required: Yes / No] (If required: signed by [patient / surrogate], filed in [location]. If verbal only: state why written consent not required per policy.)

Attestations

Student Attestation:
I discussed the proposed procedure with the patient/surrogate including indication, benefits, material risks, and alternatives including no treatment; answered questions; and confirmed understanding as documented above. [Supervising clinician name] was [present for discussion / joined after my discussion to confirm key elements].

Supervising Clinician Attestation: (Select one model; delete the other.)

• Direct participation: I personally participated in the consent discussion, confirmed patient/surrogate understanding and decision-making capacity, answered questions, and confirm the decision as documented. Presence: [in-person / remote]; timing: [throughout / joined at specific point]. Learner involvement disclosures [occurred and accepted / occurred and declined / not applicable]. I have reviewed the student's documentation and confirm accuracy [with edits as shown / without changes].
• Review-and-confirm: I reviewed the student's consent discussion with the patient/surrogate, personally confirmed capacity, voluntariness, understanding, and the decision, answered additional questions, and confirm the decision as documented. Presence: [in-person / remote]; timing: [time relative to student discussion]. Learner involvement disclosures [occurred and accepted / occurred and declined / not applicable]. I have verified the student's documentation and confirm accuracy [with edits as shown / without changes].

(Both attestations must be completed and signed/cosigned per institutional policy.)