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Informed Consent (4.17)

Informed Consent (4.17) - Policies, Clinical, UWHC Clinical, UWHC-wide, Legal Affairs

4.17

4.17 Informed Consent
Category: UWHC Clinical Policy
Policy Number: 4.17
Effective Date: January 1, 2015
Version: Revision
Section: Legal Affairs

I. PURPOSE

The University of Wisconsin Hospitals and Clinics supports the right of all patients to receive information about
their care and to participate in the development of a plan of care. The purpose of this policy and procedure is to
state the policies of the UWHC and the Medical Staff concerning obtaining informed consent for medical care, to
provide guidelines for obtaining informed consent for medical care, and to provide information concerning the
legal and ethical standards, which govern consent to medical care.

II. POLICY

A. Physician Responsibility to Obtain Informed Consent; Use of Agents to Assist. In accordance with State
law, it is the responsibility of the physician performing the procedure or providing the service to assure
that consent is obtained for treatments and procedures after the appropriate information has been
provided to the patient or, when the patient lacks decision making capacity, to his/her representative, to
allow him or her to make an informed consent decision, except in emergency or other exceptional
circumstances (see B). The treating physician will be called the "responsible physician." Other health care
professionals authorized to provide services at UWHC, including hospital staff, may assist the responsible
physician in providing the information and in obtaining signatures on consent forms to document
consent, but they do so as agents of the responsible physician who retains responsibility for: 1) the
completeness of the information and the obtaining of consent before providing medical care to the
patient or 2) the documenting of the circumstances justifying not obtaining consent (see B.).
B. Emergency Care and Other Exceptions to Consent.
1. Emergency Care. 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. In case of
doubt concerning the validity or applicability of an advance directive directing withholding
treatment, emergency medical care shall be given. When poss ible, attempts to obtain consent of
the patient or the patient's authorized representative shall continue while care is given. The
responsible physician determines the existence of an emergency. It is advisable to document in
the medical record the nature of the emergency and the efforts made to obtain consent. If blood
products are released without signed consent under this emergency care exception, it is
necessary to obtain signed consent as soon as possible for the release of subsequent products.
The emergency exception is not to exceed 48 hours without documentation of reasonable
attempts made to obtain signed consent from the patient or patient's authorized representative.
2. Advance Directive. Usually when a patient has an advance directive there will be an authorized
representative who can be given the information, give consent, and sign appropriate documents.
3. Other Exceptions. There can be other rare circumstances where other exceptions to consent may
be necessary. The Senior Vice President for Medical Affairs, Risk Management, a Hospital
Attorney, or the administrator on call may be consulted for advice in determining whether
another exception may apply.

III. PROCEDURE

A. Who May Give Consent.
1. Adults (age 18 or older) with Decision-making Capacity. Adults may give informed consent or
may refuse medical care for themselves if they are age 18 or older with decision -making
capacity. If the patient is an adult who lacks decision-making capacity, then the patient's
authorized representative must give consent, provided there is no known contrary advance
directive. Some adults with decision-making capacity choose to involve family members in the
consent process. Some patients may want to defer to the decisions of the family decision maker.
It is appropriate to show sensitivity by actively involving the family decision maker in discussions
of consent, unless the patient clearly communicates a contrary desire. However, the information
must also be provided to the patient and the patient needs to give consent. In some situations, it
may be appropriate to have both the family decision maker and the patient sign the consent
form; the patient's signature is required because it documents the legal consent. The competent
adult patient has the right to be informed and make decisions and to exclude others from the
consent process.
2. Adults Without Decision-making Capacity; Determining Decision-making Capacity; Authorized
Representatives.
a. Court Determination of Lack of Decision-making Capacity.

i. Guardian. When a court has appointed a guardian of the person, the guardian is
the authorized representative within the scope of the guardianship. The court
order should be reviewed to determine what authority has been given to the
guardian.
ii. Other Court Order. When a court has declared the patient to be in need of care
because of mental illness, substance abuse, or similar disorders, but has not
appointed a guardian, the court order or statutes determine when the patient
may still make medical decisions and when someone else is empowered as
representative. If doubts exist concerning the appropriate representative, it is
advisable to contact Patient Relations, Risk Management or a Hospital Attorney.
b. Physician Determination of Lack of Decision-making Capacity. The responsible physician
determines the patient's decision-making capacity. The responsible physician may obtain
expert consultation on the issue of such capacity. Some adults lacking decision-making
capacity may participate in decisions concerning their health care to the extent of their
ability to do so, even though they do not have full control over their care. Particularly in
situations where decisions involve major choices that could dramatically affect the health
or life of the patient, it is advisable to permit the patient with diminished intellectual
functioning to be informed and to express his or her wishes.
c. Who May Provide Consent on Behalf of Adults Lacking Decision-making Capacity. When
an adult patient lacks decision-making capacity, a surrogate decision maker should be
identified. Surrogate decision makers must be adults with decision making capacity who
are willing to make decisions for the patient. A surrogate should be identified by looking
to the individual in the highest order or priority from the list below. If there is more than
one individual in a priority category, then decisions of all individuals in the category who
are able and willing to serve as a surrogate should be unanimous, unless the individuals
in the category agree to designate one to be the surrogate. (For example, if there is no
guardian or POA, if the patient has not otherwise designated a surrogate and if the
patient has no spouse/domestic partner, but there are three adult children who are able
and willing to serve as surrogate, then all three children should unanimously agree to
medical decisions unless the three adult children agree to designate one to serve as the
surrogate decision maker.) Any such designation should be documented in the medical
record. The surrogate should be chosen by identifying the individual highest in priority
from the list below:
i. Legal guardian, unless a court has limited the guardian's powers (review court
order).
ii. Health care agent named in the patient’s Health Care Power of Attorney (POA).
Usually the appointment of a guardian ends the authority of the POA (review
guardianship court order to determine any restrictions on the POA).
iii. If there is no guardian or POA, a surrogate expressly designated by the patient
(verbally or in writing) before the patient lost decision-making capacity. The
patient’s wishes should be documented in the medical record;
iv. Spouse or domestic partner. For purposes of this policy, domestic partner
means a registered domestic partner or an individual who would qualify to
register as a domestic partner under Wisconsin law (i.e., an adult who is not
married or in another domestic partnership, shares a residence with the
patient, is unrelated to the patient and is the same-sex as the patient).
Individuals who do not fit within this definition may be considered as a possible
surrogate using the categories for “Others” or “Exceptions” below. If the patient
and the spouse/domestic partner are separated, the legal department should be
consulted to determine whether the spouse/domestic partner should still be
considered able to serve.
v. Adult child of the patient.
vi. Parents of the patient.
vii. Adult siblings of the patient.
viii. Others. When there is no one of higher priority able or willing to serve (i.e., no
guardian, POA, spouse/domestic partner, adult child, parent or adult sibling),
another close relative or friend may act as the surrogate.
ix. Exceptions. In consultation with the Hospital Attorney, exceptions to the above
priority may be authorized in unusual cases.
x. Questions or Disputes. Patient Relations or, if unavailable, Hospital Attorney is
available for consultation when determining whether an individual is an
appropriate surrogate. If the proposed surrogate has not been living with or
actively involved in the care of the patient recently or there are others involved
in the patient's care who object to the selection, such consultation should
occur. Consultation with the Hospital Attorney is encouraged when providers
are unable to resolve disputes concerning the designation of a surrogate.
d. It is the responsibility of the physician to inform the surrogate, for consent purposes, of
the information required for informed consent prior to obtaining the consent.

e. The decisions of the surrogate should be consistent with the known directions of the
patient. When there are persons who are familiar with the patient's recent preferences
regarding health care, the information that they provide should be considered. If a
surrogate insists on inappropriate treatment or refuses necessary medical care for
religious or other reasons, Patient Relations or, if not available, Hospital Attorney shall
be consulted, unless the decision is consistent with the patient's advance directive.
f. If the surrogate is not physically available to provide consent at UWHC, as necessary,
consent from the surrogate may be obtained by telegram, facsimile, or telephone (see
II.E).
3. Minors. In most cases, a parent, guardian or other authorized representative must give consent
to medical care for a minor (under age 18). Foster parents or stepparents may not sign consent
forms for their foster or step children without documented authorization, a copy of which shall be
placed in the minor's medical record. There are several exceptions where the law permits medical
care to be given to minors with the minor’s consent and without parental consent. (See Minors’
Exceptions below). Usually only medical care appropriate under the circumstances giving rise to
the exception shall be given.
4. Minors' Exceptions.
a. Emergency. In the event of a life-threatening injury or illness where emergency
treatment is needed and the parent or guardian is unavailable, parental or guardian's
consent can be presumed. In addition, where delay in treatment of an illness or injury
would increase risk of harm to the child, such as serious infection, extreme pain or
aggravation of the condition, and where it would be unreasonable for parents or
guardian to withhold consent, the physician may proceed to treat. It is advisable to
postpone emergency medical care until parent or guardian consent is obtained to the
extent that can be done without risk to the minor. The provider should continue to
attempt to seek parental consent while providing necessary emergency care and
document why consent was not obtained and the continued efforts made to obtain
parental consent in the minor's medical record.
b. Mature Minor. Where the minor is mature (this is a clinical decision made for minors who
are at least 14 years old) and the illness or injury and the treatment are understandable
by the particular minor, especially when the illness or injury is not serious and the
treatment or procedures are routine and without major risks, the minor may validly
consent to such treatment. The physician determines whether the particular minor is
mature enough to understand the information given and make an informed choice as to
treatment. It is advisable for the physician to document the existence of maturity in the
record. Even when the minor is mature, it is advisable to attempt to involve the parents
in the decision making and the minor shall be informed that confidentiality cannot be
maintained if his or her parent's insurance will be billed for the services provided. There
are some circumstances where parental involvement is contraindicated, but those
circumstances will almost always involve one of the conditions listed in paragraph d.
below where State statutes expressly authorize treatment based solely on the minor's
consent.
c. Emancipated Minor. Where the minor is emancipated (under 18, but married or in the
military service), the minor can give consent on his/her own behalf for any type of
medical care.
d. Special Circumstances When Minors May Consent. There are situations provided by
statute or case law where medical care may be provided to certain minors with the
minor’s consent (and without parental consent). If a health care provider relies on the
consent of the minor in providing medical care, in some cases the minor alone is
financially responsible for the care provided. The minor shall be informed that if his or
her parent's insurance is being billed for care, the parent will be come aware of the
procedure or treatment provided and confidentiality cannot be assured. Medical care
may be provided to certain minors with the minor’s consent (and without parental
consent) in the following situations:
i. Minors may be treated for sexually transmitted diseases without parental
consent.
ii. Minors may obtain all forms of birth control without parental consent except for
forms of birth control that are irreversible or require a surgical procedure (e.g.,
coil in fallopian tubes, such as Essure). Parental involvement in the consent
process is encouraged and if the ability of the minor to give consent is in
question, parental consent should be obtained.
iii. Minors over 14 may be tested for HIV without parental consent.
iv. Minors over 12 may receive most types of outpatient treatment for alcohol and
other drug abuse and inpatient treatment for detoxification (for up to 72 hours)
without parental consent. However, if treatment involves a surgical procedure,
administration of a controlled substance (except for detoxification), or inpatient
admission (except for detoxification), parental consent is required, unless it is
an emergency situation.

v. If the parent refuses necessary medical care for the minor on religious or other
grounds (such as a Jehovah's Witness parent refusing necessary blood
transfusions for the child), it is advisable to contact Patient Relations, Risk
Management, or a Hospital Attorney to help determine whether a court order
shall be obtained or other action taken. (See Hospital Administrative
policy-4.32-Caring for Patients who Refuse Blood Transfusions.)
vi. Regarding abortions for minors, Wisconsin law requires that, except for
situations of medical emergency, sexual assault, sexual intercourse with minor
or child abuse of the minor by a parent or other relative or custodian, or likely
suicide by the minor, parental consent as well as the minor's consent be
obtained for the abortion. Parental consent in this context means consent of
one parent, or of minor's guardian or of any adult family member of the minor.
A court, after hearing a petition of the minor (or of clergy on the minor's
behalf), can waive the parental consent requirement.
e. Minors Who Are Parents. A minor child is able to consent for care for his/her child
although he/she may not be legally able to consent for his/her own care, in most
circumstances. Becoming a parent alone does not make him/her an emancipated minor.
Parental consent for his/her care shall be obtained whenever possible.
B. When Informed Consent Must Be Obtained and Documentation Requirements.
1. Categories of Medical Care. The medical staff has divided medical care into two categories for
purposes of the documentation of informed consent: Category 1) signed consent required, and
Category 2) implied consent - signed consent not required. It is highly recommended that the
content of all informed consent discussions, whether or not signed consent is required by this
policy, be documented in the patient's medical record.
2. Signed Consent. Signed consent generally means a consent form or statement signed by the
patient or representative. When the representative is distant, consent by telephone, scanned
consent form sent/received via email or facsimile in accordance with (III.E.) is considered signed
consent.
3. Category 1 includes:
a. Procedures performed in an operating room;
b. Operative and invasive procedures requiring anesthesiology services regardless of
location;
c. Radiotherapy;
d. Chemotherapy;
e. Dialysis;
f. Transfusions of blood or blood products including cell saver blood (except albumin,
plasma protein fraction (PPF), and recombinant products);
g. ECT and psychotropic medications ordered for patients with psychiatric conditions (in-
patient psych unit);
h. All other invasive procedures, whether through an incision or natural body opening,
regardless of location performed, that appear on the attached list.
i. Other procedures where in the physician's judgment there are substantial foreseeable
risks that a reasonable person would consider in deciding whether to consent. One
signed consent form can cover a course of care or treatment such as dialysis,
chemotherapy, or radiation therapy but must be renewed if there are changes in the
patient's condition or if the treatment or therapy is changed (see III.F.). When a signed
consent is required, consent forms shall include the date and time the consent form was
signed by the patient or representative and the date and time the physician or provider
signed the form.
Signature and professional designation of the person witnessing the consent is also
required. If the physician alone obtains consent without assistance from other staff, no
additional witness signature is required unless consent is being obtained over the
telephone. A witness counter-signature is required in addition to the physician's
signature if obtaining telephone consent (see III. B.4). Nursing staff may witness the
patient's signature on the form; however, only after asking the patient or the patient's
authorized representative if he/she has been fully informed by his/her doctor or doctor's
designee of the risks, benefits, and alternatives available and determining that he/she
has no further questions. If the patient or patient's authorized representative does have
further questions or does not seem to fully understand the information that has been
previously provided, the physician shall be contacted to conduct an additional informed
consent discussion prior to the patient or patient's authorized re presentative signing the
consent form. The physician shall sign the form prior to the patient receiving blood
products or undergoing the procedure or treatment but may sign it after the patient and
witness have signed the form unless obtaining telephone consent (see III.E.).
It is highly recommended that the physician document the content of the informed
consent discussion with the patient in a progress note including the specific risks,
benefits, and viable alternatives discussed as well as any educational material provided
to the patient including documentation of use of the "teach back" method. The "teach

back" method involves asking the patient to repeat back to the physician what he/she
has heard and understood. This method allows the physician to determine patient
understanding and to clear up any misconceptions or misunderstandings the patient may
have before the patient gives consent.
4. Educational Materials. Staff is encouraged to make use of educational materials as part of the
informed consent process. Health Facts for You (HFFY) are available for many procedures and
treatments and can be very helpful when informing patients of the risks, benefits, and
alternatives available to them. Document the number of the HFFY on the patient education record
and/or in the progress note documentation of the discussion, if provided to the patient. (For more
information on HFFY, see Hospital Administrative policy 7.35-Health Facts For You.)
5. Category 2 includes: All other procedures fall into this category a nd signed consent is not
required. Generally these will be routine, noninvasive or minimally invasive procedures with no
more than minimal risk. These may include, but are not limited to, such simple and common
procedures as drawing blood, taking chest x -rays, IV placement, and arterial puncture without
line placement. It is advisable for the responsible physician to tell the patient about the nature
of the care to be given, when not familiar to the patient, and if the patient does not refuse,
consent is deemed to have been given. When Category 2 procedures are performed under
sedation, consent shall be documented as required by Hospital Administrative policy 8.38-UWHC
Adult Moderate Sedation and Hospital Administrative policy 8.56-Pediatric Sedation.
C. Physician Responsibilities. It is the responsibility of the licensed faculty physician who will be providing the
service or performing the procedure to provide the appropriate information to the patient or
representative, for responding to questions, and appropriately documenting the informed consent process
through obtaining the signature of the patient or representative on the appropriate consent form and
entering the recommended physician's note in the medical record documenting the discussion and the
decision.
1. A Graduate Medical Education (GME) trainee physician may perform these functions for a faculty
physician, but the faculty physician remains responsible. See II.A. above for use of other agents
to assist in the consent process.
2. For Category 1 medical care, the faculty or GME trainee physician is expected to obtain the
patient's (or representative's) signature (except when alternate documentation under II.B. is
used) and to sign the consent form prior to the procedure, documenting that the appropriate
information to complete the consent process has been provided to the patient or representative.
3. When a registered nurse, nurse practitioner, or physician's assistant performs an invasive
procedure, as allowed by training and hospital policy, without direct physician supervision, he/she
may sign the consent form without counter-signature by a physician. The supervising physician is
deemed to have authorized this by permitting the procedure without direct supervision and
remains responsible for the consent. A nurse practitioner or physician's assistant may also order
blood products and obtain consent for blood products if delineated in his/her collaborative
practice agreement as a delegated medical act.
4. For Category 2 medical care, staff may, in their discretion, obtain signed or documented consent
and such consent does not have to meet the requirements of this policy, thus no physician or
staff signature or counter-signature is required.
D. Use of Interpreter Services and Readers to Obtain Consent. The Hospital has had consent forms
professionally translated into a number of languages. The use of Hospital approved interpreter is
encouraged for all informed consent discussions when the patient does not speak or understand English
well, regardless of whether the form is available in the patient's native language. Sign language
interpreters are also available when conducting informed consent discussions with deaf patients. Family
and friends should not be asked to interpret for patients. Contact the Patient Relations Department to
arrange for interpreter services or refer to Hospital Administrative policy 7.53-Interpreter Services, for
more information regarding interpreter services. The person providing interpretive services shall sign the
consent form in the space provided or if using Pacific Interpreter phone or Ipad services, document the
name of the interpreter used on the consent form. Also be aware that all patients are not able to read. If
the patient requires assistance of a reader to unders tand the consent form he or she is being asked to
sign, the reader shall also sign the consent form in the space provided. Not all patients who are unable to
read will admit to this fact; therefore, the "teach back" method is recommended when conducting an
informed consent discussion. Document the name and address of the interpreter and/or reader on the
consent form or in a progress note.
E. Obtaining Consent by Telephone, Scanned Consent Form sent/received via email or Facsimile. When the
patient lacks decision-making capacity and the patient's authorized representative is not present, a
scanned consent sent/received via email or facsimile authorizing treatment from the patient's
representative is an acceptable alternative. Consent by scanned consent form sent/received via email or
facsimile shall be recorded in the medical record with an indication that basic information about the
procedure, its risks and expected results, and alternative treatments, if any, were disclosed to the sender.
Scanned consent forms sent/received via email, facsimiles, and other confirming letters are part of the
medical record.
1. It is the responsibility of the physician to assure that the person consenting to medical care for
another individual is informed of the information required for informed consent before the
scanned consent form sent via email or facsimile is sent. See II.C. for use of agents to assist in

the consent process.
2. Situations can arise where telephone consent is necessary (e.g., the patient's authorized
representative is unable to send a scanned document via email or facsimile). It is advisable for a
second professional or technical health care provider to witness the conversation by listening on
another phone. Document the time telephone consent is obtained, from whom, and the
individual's relationship to the patient. The witness shall counter-sign the consent form along with
the physician who obtains the telephone consent.
F. Lapse of Consent Forms / Duration of Consent.
1. New consent shall be obtained if the patient's condition or other aspects of the situation
surrounding the particular procedure have changed since the original consent was given.
2. New consent should usually be obtained if the patient has been discharged and readmitted to the
hospital.
3. An informed consent form is valid for one procedure or course of treatment. A new form must be
obtained for each inpatient stay prior to the administration of blood or blood products unless one
has been obtained in the outpatient setting within the previous 12-month period. Consent given
to a continuous course of treatment (e.g., dialysis, chemotherapy, radiation therapy, incision and
drainage or wound debridement, ECT, etc.) over a period of weeks or months must be renewed if
the patient's condition warrants a change in treatment, procedure, or medication regime or if the
risks and benefits or expected outcome significantly change during the course of treatment. A
consent form is valid for a maximum of a year in the outpatient setting, even if the treatment
plan remains unchanged.
G. Content of Information Necessary to Disclose During the Informed Consent Process. State law or
accreditation standards require that the responsible physician assure that the patient or representative
who is giving consent be given the following information:
1. A factual description of the proposed medical care (i.e., what is to be done);
2. What the proposed medical care will accomplish or is expected to accomplish (i.e., potential
benefits) and the likelihood of success;
3. The major serious risks of the proposed medical care and its side effects and their severity
(including potential problems related to recuperation) and what can be done about such
complications and their duration;
4. Any significant alternatives available (i.e., other modes of medical care generally considered by
the medical profession to be within the standard of care for the patient) and the risks, benefits of
these alternatives;
5. Special State Rules on Alternatives. Wisconsin Statutes and the rules of the Wisconsin Medical
Examining Board place an emphasis on disclosing alternatives, but do not require a physician to
communicate alternative modes of medical care in the following circumstances:
a. In an emergency situation; or
b. Which are experimental; or
c. Where the communication would "unduly confuse or frighten the patient"; or
d. If the patient refuses to receive the communication. If the physician does not
communicate alternatives to the patient for one (or more) of the above reasons, it is
advisable for the physician to document in the medical record the circumstances which
led the physician to determine that one (or more) of the above situations applied.
6. The possible results of not receiving the care or treatment;
7. Any research or experimental procedures, drugs, equipment, or techniques involved in the
medical care;
8. The name of the physician or other practitioner who has primary responsibili ty for the patient's
care;
9. The identity and professional status of individuals responsible for authorizing and performing
procedures or treatments. When a resident or fellow in training will be performing the procedure
or important aspects of the procedure (such as opening, closing, harvesting grafts, implanting
devices, and dissecting tissue), this fact should be disclosed and documented.
10. When indicated, the informed consent process includes a discussion about circumstances under
which information about the patient must be disclosed or reported (e.g., disclosure of information
regarding cases of HIV, tuberculosis, and other diseases that are reported to organizations such
as the state health department.
H. Informed Refusal. When proper informed consent information has been given, competent patients have
the right to make a personal decision and refuse treatment in most circumstances. However, if a patient
exercises this right, it shall be indicated in the medical record that he or she was advised a bout the risks
involved in refusing treatment and the reason given by the patient for refusing treatment. When a patient
refuses recommended treatment, he or she shall be advised to obtain a second opinion, and this
discussion shall also be documented. An ethics consult may be appropriate in certain circumstances. If the
patient is consenting to a procedure but is refusing blood products, this refusal should be indicated on the
front of the consent form.
I. Withdrawal of Consent. An adult patient with decision-making capacity may withdraw a consent previously
given to any medical care. Such withdrawals shall be honored. In rare cases where immediate withdrawal
in the middle of treatment may be either life threatening or pose immediate and serious problems to the
health of the patient, termination of treatment may be temporarily postponed while the situation is

assessed. Where the patient lacks decision-making capacity, the patient's authorized representative can
generally withdraw consent if this is not inconsistent with the patient's prior express wishes. When the
patient's prior wishes are not known and the decision to withdraw consent appears to be contrary to the
best interests of the patient, termination of treatment shall be temporarily postponed while the situation is
assessed. When the decision is to withdraw treatment necessary to support life, see Hospital
Administrative policy 8.25-Guidelines for Decisions to Limit Life-Sustaining Medical Treatment.
J. Research and Clinical Trials. Clinical research requirements for informed consent are governed by federal
informed consent regulations and State laws and regulations and are contained in Hospital Administrative
policy 4.24-Clinical Research Guidelines.
K. Contact Persons. The Patient Relations Department, Risk Management, the Hospital Attorney, or the
Administrator on Call may be contacted for advice concerning problems with patient consent.

IV. REFERENCES

Wisconsin Medical Practice Act, Section 448.30, Wisconsin Statutes;
Rules of the Medical Examining Board (Wis. Adm. Code, Med. 18.05);
The Joint Commission (TJC) Standards, RI 01.01.03, 01.02.01, 01.03.01, 01.04.01 (2009 manual); CMS Conditions
of Participation: Surgical Services Standard 482.51, Tag A250,Patient Rights Standard 482.13(a) and (b), Tags
A0117, A0130, 0131, A0132

V. FORMS USED

The hospital provides a standard form - Consent to Operations, Anesthetics, Diagnostic Radiology, Transfusion, or
Other Special Procedures, UWHC Form #9139 that shall be used in most instances to document informed consent.
Individual departments, services, and practitioners may use alternate forms if first approved by Risk Management
and Health Information Services (HIS), when applicable. See Hospital Administrative policy 10.24 -Electroconvulsive
Therapy (ECT) for ECT consent form and requirements and Hospital Administrative policy 4.30- Consent for HIV
Testing & Release of Protected Health Information for HIV testing consent form and requirements.

VI. COORDINATION

Sr Management Sponsor: Sr. VP & General Counsel
Author(s): Associate General Counsel; Director, Risk Management
Review/Approval Committee(s): UW Health Clinical Policy Committee; Medical Board

SIGNED BY

Ronald Sliwinski
President and CEO
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee