UPDATE: Documentation of Consent for Procedures or interventions during COVID | April 4

From: Dr. Ben Williams, Acting VP, Medicine, Elin Bjarnason, VP, Clinical Operations, and Cheryl Damstetter, VP, Priority Populations and Initiatives.

The processes for obtaining informed consent from patients or their decision makers have not changed. This memo details temporary changes to the documentation of consent only. In Island Health Consent for surgery and other procedures is documented on an Island Health Consent form that is signed by the person giving consent (usually the patient). Although consent legislation does not detail how consent is to be recorded, the use of a consent form signed by the patient is considered best practice and serves as a record of the conversation that took place between the Provider performing the procedure and the patient.

In light of concerns from physicians and staff about the possible transmission of COVID and recommendations to not take clipboards and charts into patient rooms when Infection Control Precautions are in place, the following recommendations have been advised by Risk Management and Legal.

1. Whenever possible written signed consent from the person providing consent should be obtained.

2. When a Provider assesses that having the patient sign the consent form would pose a significant risk (such as the patient is on droplet precautions), the Provider should have a verbal discussion with the patient or appropriate decision maker about consent. It is strongly recommended that this discussion is documented in the progress notes, and include at a minimum:

a. The time and date

b. Specific procedure

c. Explanation of risks

d. Questions or comments

e. Consent provided or refused

f. Name of person providing verbal consent

3. In order to ensure that other members of the team responsible for verifying consent are aware, the Provider should make a note on the consent form indicating that consent was obtained verbally due to infection risk and to refer to the progress note by date where it is recorded.

Providers with specific questions about individual cases are advised to consult with CMPA, CNPS or BCMPP as appropriate.

Staying informed:

  • Visit Island Health's ‘source of truth,COVID-19 WEB PAGE on the Intranet. Transcripts or recordings of the Town Halls will be posted after each event.
  • The Medical Staff website has specific information for medical staff.
  • Check the BCCDC’s web site for bulletins on emerging respiratory viruses and the most current information, the case definition and instructions on infection control measures for patients who present with symptoms.
  • BCCDC is now posting on its website the number of confirmed cases and number of samples tested in BC.
  • We are also posting information for the public on our social media channels. We encourage you to follow/retweet/share BCCDC’s and Island Health’s posts.