Informed Consent in Practice

By VeriScorePrep Team · 4 min

Informed consent is a process, not a signature. A signed form without the underlying process is not valid consent.

The elements

• Capacity: the client can understand the information, appreciate the situation, reason through options, and communicate a choice. Capacity is decision-specific and may fluctuate — assess for each decision.
• Disclosure: provide the nature of the service, expected benefits, risks, alternatives (including no service), and likely outcomes — at the client's level of comprehension.
• Comprehension: confirm understanding; ask the client to restate the decision in their words.
• Voluntariness: the client is free from coercion; the choice is theirs.

When capacity is impaired

A legal guardian or surrogate may provide consent. Where there is no surrogate, an ethics consultation or legal pathway may be required. Document the capacity assessment — not just your conclusion but the basis.

Special cases

• Minors: typically parents consent; mature minor doctrines vary by jurisdiction. Assent is sought from the child where developmentally appropriate.
• Emergency: when imminent risk exists and the client cannot consent, emergency care proceeds; documentation captures the basis.
• Research: more stringent standards, IRB oversight, special protections for vulnerable populations.

Refusals are also choices — document them, explore the basis, and offer alternatives.