Informed Consent and Patient Rights
This domain tests whether you can explain a test or treatment, obtain a valid consent or refusal, and prove it in the record.
Elements of consent
Informed consent is a process, not a signature. It requires: the diagnosis or condition; the nature and purpose of the proposed test or treatment; material risks and expected benefits; reasonable alternatives, including no treatment; and the likely consequence of declining. Consent must be voluntary and given by a patient with capacity.
Who may consent
Indiana's health care consent statute (IC 16-36-1) sets out who may consent for a patient who cannot: a guardian, a health care representative, a spouse, and certain relatives in a defined order. A friend who drove the patient does not automatically qualify. The age of majority is 18; parental or guardian consent is the default for minors, with narrow statutory exceptions.
Special situations
- Emergency: consent is implied for treatment needed to prevent serious harm when no authorized person can be reached.
- Informed refusal: a competent patient may decline. Your duty is to explain the consequences and document the discussion, not to override the choice.
- Prescriptions: a completed exam or successful contact lens fitting entitles the patient to the prescription; release cannot be conditioned on payment or on buying from you.
Worked example
A 58-year-old declines dilation because she is driving. You explain that without dilation a retinal tear could be missed, offer a return visit within a week, and record both the advice and her choice, plus a specific warning-sign list. That is informed refusal; a bare note reading 'patient refused' is not.
Traps
Treating a signed form as the whole of consent; accepting consent from whoever happens to accompany the patient; stretching the emergency exception to cover convenience; documenting a refusal without documenting the warning you gave.