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Information

  1. NO SURGICAL PROCEDURE, HOWEVER MINOR, CAN PROCEED WITHOUT THE VOLUNTARY, INFORMED, AND WRITTEN CONSENT OF THE CLIENT.
    1. Surgical permits are witnessed by the physician, nurse, or other authorized person.
    2. Surgical permits protect the client against unsanctioned surgery and also protect the surgeon and hospital staff against claims of unauthorized operations.
    3. Informed consentmeans that the operation has been fully explained to the client, including possible complications and disfigurements, as well as whether any organ or parts of the body are to be removed.
    4. Adults and emancipated minors may sign their own operative permits if they are mentally competent; permission for surgery of minor children and adults who are incompetent or unconscious must be obtained from a responsible family member or guardian.
    5. The signed operative permit is placed in a prominent place on the client's chart and accompanies the client to the operating room.
    6. Legal issues in the emergency department: record-keeping plays an essential role in both the prevention and defense of malpractice suits. Detailed documentation not only provides for continuity of care but also perpetuates evidence that care was appropriately given. Records should:
      1. Be written legibly.
      2. Clearly note events and time of occurrence.
      3. Contain all laboratory slips and results of other tests.
      4. Describe events and clients objectively.
      5. Clearly note physician's parting instructions to the client.
      6. Be signed where appropriate, such as with doctor's orders.
      7. Contain descriptions of every event that might lead to a lawsuit, such as fights, injuries, equipment failures.
    7. Consent—although there is no law requiring written consent before performing medical treatment, all elective procedures can only be performed if the client has been fully informed and voluntarily consents to the procedure.
      1. If informed consent cannot be obtained because of the client's condition and immediate treatment is necessary to save life or safeguard health, the emergency rule can be applied. This rule implies consent. However, if time allows, it is advisable to obtain either oral or written informed consent from someone who has authority to act for the client.
      2. Verbal consents should be recorded in detail, witnessed and signed by two individuals.
      3. Written or verbal consent can be given by alert, coherent, or otherwise competent adults, by parents, legal guardian, or person in loco parentis (one standing in for the parent with the parent's rights, duties, and responsibilities) of minors or adults who are incompetent.
      4. If the minor is 14 years old or older, consent must be acquired from the minor as well as from the parent or legal guardian. Emancipated minors can consent for themselves.