Referrals must be made in accordance with the regulations - Relevant Provision2.
Referrals must be in writing, signed by the referring practitioner and dated - Relevant Provision 3.
Focus on policies, not forms Instead of focusing on hospital consent forms, the new Guidelines focus on the need for hospital policies to support the informed consent process – to assure that patients receive adequate information, provided in a manner they can understand, so that they can effectively exercise the right to make informed decisions concerning treatment.
Because the referral must be received before the service is provided, any back dating by the referring practitioner would be a false statement capable of being used to claim a benefit - Relevant Provision9.
With respect to consent forms themselves, the new Guidelines list the following minimum requirements for procedures or other types of medical treatment requiring informed consent: Recommended documentation It is recommended that the physician carefully document in the hospital medical record that a discussion was held with the patient and that informed consent was obtained.
This documentation can be accomplished in a variety of ways – through a chart note in the progress notes of the patient’s record, through a note in the patient’s history and physical, through a certification provision on the consent form itself (if the form contains one), or through documentation provided from the physician’s office (e.g., an informed consent form signed by both the patient and the physician).
However it is done, the description of those procedures requiring informed consent should be appropriately documented and approved by the medical staff’s executive committee.
Footnote This advisory is a publication of Davis Wright Tremaine LLP.