Consent, Capacity and Enforcement
Patients have the right to refuse or accept healthcare investigations and interventions. Consent is sometimes implied by decisions or actions. In many cases, however, it needs to be explicitly informed and documented in the legal record of care. All formal consents must be recorded in the Connect Care clinical information system (CIS).
Sometimes patients are compelled to accept healthcare investigations and interventions. Provisions of the Mental Health Act set criteria that must be met, and processes that must be followed, when patient's lack capacity and are a threat to themselves or others. Provisions of the Public Health Act set criteria for compelling a non-consenting patient to testing, treatment or isolation related to a communicable disease posing a public health threat.
Documentation of consent and capacity for healthcare decision-making is streamlined through Connect Care's "Consent & eForms Navigator" (formerly known as the Consent Navigator). Additionally, orders can be placed to document and flag that patient care is subject to provisions of either the Mental Health Act or the Public Health Act.
Key Points
All informed, written, expressed verbal and implied consents are documented in the CIS.
Documentation occurs in the Consent & eForms Navigator, not clinical notes.
eSignatures can be captured with pads, tablets or computer pointing devices.
Conventional signatures can be scanned from printed consent forms.
SmartText can be used to customize text fields within consent forms.
Relevant persisting consents can be pulled forward from encounter to encounter.
A "capture signature" box on a form indicates where a signature is required, with red font indicating that it is mandatory and grey font indicating optional.
Once a consent form is signed and saved in the CIS, it becomes read-only.
Revoking consent requires completion of a new consent form.
Consent Notes can be used to document consent interactions that do not involve forms or signatures.
--> All consent forms and processes are facilitated by the Consent & eForms Navigator, which can be found on the patient Storyboard.
Special Situations
Some consent and legal constraints documentation needs may be complicated by unique challenges, as may occur in custody, abuse, forensic and disciplinary contexts. A tip sheet provides instruction about how to document such situations and associated legal advice.
More Information
How-to Resources
Guide: Consent & eForms Navigator (step-by-step instructions for all scenarios; comprehensive)
Demonstration
Resources
MyLearningLink: Epic – Confidentiality Features in Connect Care (this module helps Connect Care users develop knowledge and understanding of the confidentiality features and context for their use)
Knowledge Library Resources (use keyword 'consent'; includes tips and guides for all disciplines and a wide range of consent types)
AHS Consent Policies (detailed information)
Questions: ConnectCare.Consent@ahs.ca