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RI-275 Permits for Medical and Surgical Procedures

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RI-275 Permits for Medical and Surgical Procedures Title: Permits for Medical and Surgical Procedures Number: RI-275 Dept: Baton Rouge General Medical Center Effective Date: Authority: Operations Council, Medical Staff Review Dates: 3/03 Revised: 6/00, 3/02, 2/04, 6/04; 2/05; 6/05; 11/05; 10/06; 11/07 PURPOSE: To establish guidelines for obtaining and documenting permits and informed consents at the Baton Rouge General Medical Center (BRGMC). POLICY: 1. Any procedure requiring an Informed Consent will automatically require a Baton Rouge General Permit for Surgical/ Medical Procedure and Acknowledgment of Receipt of Information. If the patient arrives to the BRGMC with an informed consent for surgery from the physician’s office, the Permit for Surgical/Medical Procedure and Acknowledgement of Receipt of Information Form is not required. 2. The permit will be completed by an RN or LPN. Exception: Technologist in the Imaging Department and Respiratory Therapist in the stress lab will complete permits for the procedures they perform i.e. Intravenous (IV) Contrast, stress test. 3. An informed consent is required on: A. Operative or invasive procedures/treatments. B. All procedures in which anesthesia is used, regardless of whether entry into the body is involved. C. Invasive diagnostic procedures. D. Experimental procedures. E. Investigational medication. F. Autopsy (non-coroner’s case) G. HIV testing (non-exposure). H. Blood, prior to type and cross match and type and screen. (One per hospital visit). I. Non-invasive procedures that may potentially place the patient at risk. Some non-invasive procedures include, but are not limited to, the following a. Cardioversion b. CAT Scan/MRI with contrast c. Closed Reductions d. Radiotherapy e. Stress Testing f. Hyperbarics 4. Louisiana law provides that the attending physician is responsible for and is the only one who can obtain an Informed Consent from the patient before instituting any medical-surgical procedures or treatments that require informed consents. The physician is responsible to inform the patient of the risks, benefits, and alternatives of the planned procedure. 5. The explanation and the patient's understanding of the above information will be documented in the medical record. 6. If the patient has any questions concerning the nature, purpose or risks of any procedures or alternatives, they should be referred to the physician prior to signing the permit. 7. A patient may sign his/her hospital permit at any time after medications as long as he/she is oriented to person, place, and date. The nurse should document the patient’s orientation in the nurse’s notes if the medication was a sedative or narcotic. 8. When the patient cannot give permission, and the next of kin is not immediately available, permits may be obtained via telephone. POLICY: Title: Permits for Medical and Surgical Procedures Page 2 of 3 Number: RI-275 A. The physician should call a family member to explain the nature, purpose, risks of procedure and alternatives. B. A professional staff member will then read all contents of the permit form to the family on the phone and document this information in the Nurse’s Notes. C. A phone permit must be obtained with two witnesses, one of which will be a professional. This may be done by extension phone where two employees listen to conversation, or serial conversation if only one phone available. The first person gets the permission; the second person verifies whom the person is/relation to patient, what he consented to and, any other necessary data that may be needed. D. It is imperative to indicate on the permit that this was phone consent. Both witnesses must sign the permit. 9. Persons who may consent to surgical or medical treatment (LSA 40. 1299.53). “In addition to such persons as may be authorized and empowered, any one of the following persons in the following order of priority, if there is no person in a prior class who is reasonably available, willing, and competent to act, is authorized and empowered to consent, either orally or otherwise, to any surgical or medical treatment or procedures including autopsy not prohibited by law which may be directed by a duly licensed physician: A. Any adult, for himself. B. The judicially appointed tutor or curator of the patient, if one has been appointed. C. An agent acting pursuant to a valid mandate, specifically authorizing the agent to make health care decisions. D. The patient’s spouse not judicially separated. E. An adult child of the patient. With multiple children present, all must be in agreement. F. Any parent, whether adult or minor, for his minor child. G. The patient’s sibling. H. The patient’s other ascendants or descendants. Any person temporarily standing in loco parentis, whether formally serving or not, for the minor under his care and any guardian for his ward. 10. BRGMC recognizes the right of a minor in Louisiana to consent to medical or surgical services by a hospital or by a physician licensed to practice in the state when the minor believes himself/herself to be afflicted with an illness or disease, in which case the minor’s permit shall be valid and binding. 11. In an emergency situation requiring surgical/medical treatment, the physician should note this situation in the medical record and proceed with the emergency surgery/medical treatment. NOTE: An emergency situation is defined by Louisiana law as, “a situation where, in competent medical judgment the proposed surgical/medical treatment or procedure is reasonably necessary and the patient is not in a condition to give permission, or a person authorized to consent as listed above is not readily available and any delay in treatment could reasonably be expected to jeopardize life/health of affected person or could reasonably result in disfigurement/impair faculties. A consent to medical/surgical treatment/procedure suggested, recommended, prescribed, or directed by a duly licensed doctor will be implied where an emergency exists.” 12. In situations where the patient is unable to consent and no responsible relative can be located, it is necessary to contact the BRGMC Legal Services department so that a petition can be filed in the appropriate court for either permission to be granted by the court or for the court to designate an individual to serve as a guardian. Following such court action, the documentation granting authorization to the BRGMC to treat the patient shall be made a permanent part of the patient’s medical record. 13. There is no absolute limit on the period of time of validity of a consent or documentation of consent by signature on a form. If patient’s condition or available treatments change significantly, the earlier consent is no longer valid and a new one should be obtained; otherwise, consent is legally valid until withdrawn. 14. Verbal consent may be obtained by patients unable to sign permit form due to physical disability, illness, etc. It is imperative to indicate on the permit that this was verbal consent. Must be obtained with two witnesses. 15. At the time of admission, all patients are required to sign forms authorizing the BRGMC to release information to insurance carriers, attorneys, etc. for the purpose of settlement of the patient’s account; also authorizing the BRGMC and the attending physician to proceed with examinations, procedures and/or treatment as indicated by the patient’s complaint and subsequent findings. POLICY: Title: Permits for Medical and Surgical Procedures Page 3 of 3 Number: RI-275 16. It is the physician’s responsibility to discuss the patient’s Do Not Resuscitate (DNR) status with the patient or patient representative, when applicable. PROCEDURE: 1. Documents needed: A. Physician’s order B. Baton Rouge General Permits for Medical/Surgical Procedure C. Layman’s terms 2. Documentation must be legible; black ink is preferred. No blanks are to be left unfilled. Write N/A (not applicable) in spaces not pertaining to patient. 3. Complete Permit form: A. Patient Label B. Date/time of completion C. Full legal name of patient. Check correct legal spelling of name. D. First and Last name of physician(s) doing the surgery/procedure. E. Name of surgery/procedure using appropriate medical terminology. Do Not use abbreviations. Differentiate between right/left when procedure involves a limb, eye, lung etc. Be specific with digits i.e. thumb, first second third finger, etc. and levels of the spine L2, L3, etc. If any difference exists between physicians’ orders, the operating room schedule or patient’s perception of which side is to be operated on, the physician is to be notified. F. Allergy to an anesthetic and/or drug must be listed in space authorizing use of anesthetics. G. Write in layman’s terms for the medical/surgical procedure being performed. H. Obtain signatures. I. Witness the signature (two witnesses required for verbal and telephone consents; one of which will be a professional). J. Document date and time of signatures. 4. Place permit in medical record. ASSOCIATED FORMS: MR-OHC-1066 Informed Consent not online MR-NS-1454 Anesth Consent MR-NS-1137 Permit for Medical and Surgical Procedures .
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