Sample Outline of Informed Consent
For example, I use a specific consent format to help ensure a quality treatment. Consent must be given for the forms the patients receive, the assessment you give, and for the treatment. For the most part, all consent has the same format, but there are some slight differences depending on what part of the process you are in. You may use a formal format or a conversational consent.
Health Care Forms: (30 seconds)
1. All information must be explained to the client. What are they looking at? The first page is your consent form that goes over the process and office policy. The second form is your health history, please fill it out to the best of your knowledge.
2. Why is this information being collected? Example: This information is collected to help us treat you better. It is not used for marketing.
3. What are we doing with this information? The information belongs to the patients but we will keep it on file in order to give informed treatment.
4. That all the information is private and is not shared with anyone other than the therapists.
5. Ask if they have any questions.
6. Consent.
Assessment: (should only take 1 min)
1. Explain the process and the steps. What are you going to do. Example: So we are going to do a short assessment today that involves me asking some questions, possibly touching you, and watch you do some motions.
2. Why are we conducting the assessment? This assessment is to better help me understand why you are coming in today and identify and risks that might be present during treatment. It will also help me know your likes and dislikes as well as design a treatment plan for you.
3. What are the risks associated with the assessment? If we are examining your injury you may experience some pain when we touch or move it.
4. What are the consequences of not having the assessment? We may not be able to treat you appropriately and target what you want. Or you may be injured during treatment because we did not have accurate information.
1. Stop or modify.
2. Do you have any questions?
3. Consent.
The best way to transition from the assessment part of the process into the treatment, is to repeat back what you think are the main take away points of the assessment conversation. Try: “So what I am hearing is you are feeling that _______________________ and ________________ are your main concerns, and you would like to focus on ___________________ in order to treat __________ . Is that correct?”
Then you move into a treatment suggestion based on your expert opinion of their needs. This is your verbal “treatment contract.” It is the time where you act as a health care advocate to guide the treatment. Be detailed and be clear, so that they have a very good understanding on what exactly they are agreeing to. Many unhappy patients are only patients who had one idea of what their treatment would be and were instead delivered another. This is the time where the patient and the practitioner come together. Remember consent is a state, not a one time event so even after this discussion, you need to stay in touch and continue to advise.
Consent for treatment: (should only take 1 min)
1. Explain how the time will be managed, all time must be handled up front. Please explain why the treatment may be shortened if necessary. Example: Today we have 55 minutes, we are starting a little late due to you train issue, but I can make up 5 minutes on the other end so we are not too off.
2. Explain what parts of the body will be touched. Example: Today we are doing a modified full-body treatment, so I will not need access to your arms, but I will be touching our back, front of legs, back of legs and glutes, cervical spine, and head. I suggest you help the client understand if they are looking for a full-body, upper body, only lower body or just a spot treatment. They may not understand the possibilities.
3. Explain what techniques you will be using to “solve” their problem using non-medical terms. Example: ‘Because you have what seems to be a stiff neck, we will be using very gentle treatment. It will be mostly gentle skin depth pressure and range of motion rather than traditional massage.
4. What are the benefits? Why have you chosen this for them? I choose this for you because based on what you explained, I think this is the best way to help you feel more comfortable based on.
5. What are the side effects they might experience? Because we are using that skin pulling technique, you can experience uncomfortable skin stretch or red marks on the skin.
6. What are the risks? With any treatment, you may have a poor reaction or if there is an underlying problem, you could aggravate that problem so it may make it worse.
7. Stop or modify. At any time you can stop or change what we are doing.
8. Ask if they have questions.
9. Consent.
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