Taking a proportionate approach
Not every paragraph of this guidance will be relevant to every decision that you make with or about a patient. Your judgement about how to apply the guidance will depend on the specific circumstances of each decision, including:
- the nature and severity of the patient’s condition and how quickly the decision must be made*
- the complexity of the decision, the number of available options and the level of risk or degree of uncertainty associated with any of them
- the impact of the potential outcome on the patient’s individual circumstances
- what you already know about the patient, and what they already know about their condition and the potential options for treating or managing it
- the nature of the consultation.
Obtaining a patient’s consent needn’t always be a formal, time-consuming process. While some interventions require a patient’s signature on a form, for most healthcare decisions you can rely on a patient’s verbal consent, as long as you are satisfied they’ve had the opportunity to consider any relevant information (see paragraph 10) and decided to go ahead.
Although a patient can give consent verbally (or non-verbally) you should make sure this is recorded in their notes.*
For some quick, minimally or non-invasive interventions – particularly examinations – it would be reasonable to rely on a patient’s non-verbal consent. Examinations are a necessary part of diagnosis, and it’s reasonable to believe that a patient presenting for a consultation wants to be diagnosed.
However, even for such routine procedures you should:
- explain what you’re going to do and why
- make clear the patient can say no, and stop immediately if they do
- be alert for any sign that they may be confused or unhappy about what you are doing.