University of Wisconsin Hospital and Clinics
TITLE: Informed Consent for Dialysis
and Related Procedures
REVISED: January 1, 2017
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Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, DNP, RN, NEA-BC
Medical Director: Alex Yevzlin, MD
The purpose of this policy is to state the practice of the UWHC Dialysis Department and the
Nephrology Medical Staff regarding informed consent for Hemodialysis and related procedures.
Refer to UWHC Administrative Policy 4.17 Informed Consent for detailed information
regarding obtaining informed consent, the legal and ethical standards for obtaining consent for
medical care, and the documentation requirements for informed consent.
A. It is the responsibility of the physician making arrangement for the procedure or
treatment to assure that informed consent is obtained prior to the treatment and/or
1. In an emergency, when the patient is unable to give consent and delaying medical
care until a patient's authorized representative can be found risks serious injury to
health or significant pain, medical care may be given to the extent needed to respond
to the emergency needs of the patient, provided there is no known advance directive
to the contrary.
B. A signed informed consent is required for each of the following dialysis procedures:
1. Hemodialysis or Continuous Renal Replacement therapy
2. Insertion/Removal of Central Venous Catheter (CVC).
3. For a detailed list of procedures see Policy 4.17, Section III, B. When Informed
Consent Must Be Obtained and Documentation Requirement.
C. An informed consent form is valid for one procedure or course of treatment.
1. Dialysis is considered a continuous course of treatment that occurs over a period of
weeks or months. Consent must be renewed if the patient's condition warrants a
change in treatment or procedure, or if the risks and benefits or expected outcome
e.g., AKI to ESRD significantly changes during the course of treatment.
2. A consent form for a continuous course of treatment is valid for a maximum of one
year if the treatment plan remains unchanged.
A. Use Consent to Operations, Anesthetics, Diagnostic Radiology, Transfusion, or other
Procedures – Renal Replacement Therapy (301644-DT) and/or Consent to Operations,
Anesthetics, Diagnostic Radiology, Transfusion, or other Procedures – Central Line
Placement (301551-DT). These forms are readily available on the dialysis unit and can
also be printed from U-Connect.
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B. A generic Consent to Operations, Anesthetics, Diagnostic Radiology, Transfusion, or
other Procedures (UWHC form # 1289139) form is available for use on the inpatient
units. The obtaining provider is responsible for writing in an accurate description of the
procedure being performed on the consent form.
C. Document filing:
1. Paper consent forms will be scanned into the electronic medical record per UWHC
Policy 6.26 Medical Record Retention Policy.
2. If the patient is a VA patient and consent is obtained at the UWHC Dialysis
Department the consent form needs to be faxed to the VA Hospital Medical Records
Department (fax # 608-830-6655).
3. If the consent is obtained at Middleton Veteran Administration Hospital contact the
appropriate VAH Inpatient Unit and ask that a copy of the consent form for dialysis
be faxed to UWHC Hemodialysis department (fax # 608-262-4893). The faxed copy
will be subsequently scanned into the electronic medical record per UWHC Policy
6.26 Medical Record Retention Policy.
A. UWHC Administrative Policy 4.17 Informed Consent
B. UWHC Policy 6.26 Medical Record Retention Policy
REVIEWED: Jan 2016 Jan 2017