Why only surgical consent
I believe
all patients should sign a medical consent also. It can solve most of the
medicolegal problems. I have designed one. Kindly send your inputs before I ask
the association or the council to approve it.
Dr KK
Aggarwal
MEDICAL CONSENT FORM
Date:
1.
Name:
2.
Age:
3. Sex:
4.
Email: 5. Mobile
No: 6. Address:
I, hereby give medical (general/specific) consent for my
treatment under Dr _________________________
I have read and understood the enlisted information
and the same also has been conveyed to me in my own language and I have cleared
all my doubts.
1)
I understand that my treating doctors _________ are honorary
consultants and not hospital employees.
2)
Being honorary consultants, they provide consultancy to
their patients morning and evening at pre-defined times and they are on call
for SOS consults.
3)
During their absence, the hospital provides cover through
resident/floor doctors who are under the payroll of the hospital.
4)
In emergencies, the hospital provides resident/Intensivist
cover. They are qualified doctors specialized only in this job. They may shift
the patient if need arises to the intensive care unit. They are
authorized to act independently as per the need of the situation.
5)
The night coverage is provided by the hospital
residents/floor doctors. The treating consultants are available on phone in the
night but for any emergency it is the hospital which provides the intensive
care coverage to tackle any unforeseen event. The hospital will charge
separately for these facilities.
6)
I understand that there may be situations when there is an
emergency and the treating consultants may not be available for hours. In that
case the hospital intensive care unit will provide necessary cover and take
appropriate need based decisions.
7)
I understand that nursing care is provided by the hospital
and is not under the direct charge of honorary treating consultants.
8)
If there is any problem with the nursing care, I/my
relations need to contact the floor nursing manager for the same.
9)
I understand that Diet services are provided by the hospital
through a hospital dietitian who can be approached through the nursing
staff. Treating doctors directly do not control the dietary services.
10)
I have been told that doctors do not guarantee cure.
They only provide treatment and do investigations to the best of their skills,
acumen and knowledge.
11)
I understand that there may be a situation may arise where
even after days of admission, the diagnosis may not be made by my treating
consultants and in that situation I hereby authorize by primary treating
doctor/s to call upon other specialist to give a second opinion. The fee for
these specialists will be charged separately.
12)
I understand that my treating doctors have no objection to
discuss my case with my primary referral doctor or a family physician.
13)
I hereby authorize my treating doctor/s to investigate me to
the best of their skill and knowledge and which should be in my best interest.
14)
I understand that there is theoretical risk of sudden
cardiac arrest in patients with uncontrolled blood pressure, uncontrolled
diabetes, unstable heart blockages, morbid obesity, abnormal lipids, acute
febrile illness (dengue, pneumonia,) etc. Sometimes while the patient is in the
ward he or she may develop cardiac arrest due to lung clots ( pulmonary
embolism) which may be life threatening. This usually happens when the person
is lying on the bed for some time.
15)
I understand that it is my responsibility to tell the
doctors on a daily basis if I do not pass motion/flatus after 24 hours of stay
in the hospital or if I do not pass urine in less than 8 hours on any day.
16)
I understand that in spite of the best care by the hospital
there may be an accident of fall from the bed. To prevent that except in the
intensive care areas, I am supposed to provide and keep an attendant with me.
17)
I hereby give permission and authority to my treating
doctors for certain invasive procedures like fluid aspiration, dressing,
internal cavity fluid aspirations, etc. Each one of them may have
some inherent complication rate including a rare mortality.
18)
I understand that even giving intravenous fluids is not
without any risk. There are chances of developing inflammation,
infection, drip reaction (fever and chills), oozing of blood, and swelling from
the IV site.
19)
I hereby also give consent for any radiological
investigation/s which may include ultrasound, CT scan, MRI, etc. I
understand that any x-ray or CT imaging involves radiation risk.
20)
I hereby authorize my treating doctor/s to go ahead with
necessary investigations irrespective of the cost in the in the best interest of
my condition.
21)
I have been explained about the hospital charges including
the policy of advance payment and will abide by the same.
22)
I understand that a situation may arise where I may need a
blood transfusion. I authorize hereby my treating doctors to arrange necessary
blood from voluntary donors for transfusion. The hospital may ask for replace
of the donor.
23)
I understand that the blood bank is a hospital department
and the blood is issued by them and transfused by the nurses under the
supervision of the hospital resident/floor doctor/s. The treating
consultant/s’ role is only to decide whether a transfusion is required or
not. If any blood transfusion reaction occurs it is the responsibility of
the hospital and not the treating doctors.
24)
I understand that it is my duty to disclose on oath all my
previous illnesses at the time of admission. Any false information added to
Mediclaim may amount to a fraud.
25)
I have declared my history of any drug allergy, history of
pass illnesses and personal history including my habits and addition at the
time of admission and same cannot be changed unless provided by proofs.
26)
I have checked the spelling of my name, age and address at
the time of admission as it may be difficult to change these parameters at the
time of discharge or after the discharge.
27)
There are certain medical procedures which are sometimes
necessary in the medical treatment that may include putting in a ryles tube,
urinary catheter, etc. I hereby give consent for the same.
28)
I understand that nothing comes free in a corporate
hospital. I have to pay for all consumables which may include gloves,
hand sanitizer, tissue paper, soaps, thermometer, etc. I have the right
to carry back these disposables which have been issued/billed to me.
29)
Many of the consumables may not be covered by the
Mediclaim policy/Public sector undertaking/Government units. For these I may be
billed separately and may have to pay cash. It is my duty at the time of
admission to clarify with the admission office as to which are the items which
are not reimbursable.
30)
I understand that hospital does not accept cheques and I
have to pay either in cash or by demand drafts.
31)
I understand that if I pay by credit card, the charges may
be extra.
32)
I understand that being a corporate intuitions, there are no
provisions for concessions. The treating doctor/s should not be embarrassed for
the same as they may have no role.
33)
I understand that hospital charges more money for inpatients
for certain investigations/procedures compared to outpatients.
34)
I understand that hospital does not allow bringing any food
from outside or buy medicine or devices from outside.
35)
I understand that the hospital policy does not allow
children to visit the hospital as relations.
36)
I understand that there are strict visiting hours which my
relations might have to abide.
37)
I understand that hospital does not allow flowers to be
brought within the hospital premises.
38)
I understand that hospital is a smoking-free zone.
39)
I understand that hospital will provide vegetarian healthy
diet.
40)
I understand that hospital will not permit me to buy
medicines or procure devices from outside hospital pharmacy.
41)
I understand there is a separate counter in the
hospital to assist for Mediclaim or PSU formalities. It is my/my relations’
duty to get Mediclaim farm issued from the counter and get it signed by the
treating consultant and get it faxed to the TPA. It will be my duty (not my
treating consultants) to follow it up with the TPA through the TPA desk. The
TPA form needs to be submitted within 24 hours of admission. If there is a
delay, the primary doctors will not be responsible or the same.
42)
I understand that on the day of discharge it may take 6-8
hours by the Mediclaim counter or the TPA to process my queries and finally
sanction the claim.
43)
I understand that if I leave the hospital in the night, I
may end up in cancellation of my Mediclaim policy.
44)
For any ward leave, I need to contact the treating
doctor/floor doctor/floor manager/floor nursing staff and need to provide the
reasons for the same.
45)
I understand that the Mediclaim insurance will cover only 1%
of my insured amount as the room rent (2/% for intensive care). If I upgrade
any room, my charges will increase for other services also and insurance
company may reimburse me for my room/other services as per original
entitlement.
46)
I understand that the hospital charges may be different for
different categories of patients. It is not like a hotel where the
difference is only in the room rent. The charges of surgery, anesthesia,
doctors fee, etc. may vary as per the bed category chosen.
47)
I understand that at the time of admission, the doctor/s may
admit you with a provisional diagnosis (disorder A) and may end up in getting a
diagnosis (disorder B) for which investigations and treatment facilities may not
be available in the hospital and hospital may ask for a transfer to other
hospital.
48)
I understand that the hospital may not have 100% facilities
available in the world.
49)
In case of sudden cardiac arrest in the hospital premises,
the hospital policy is to Alarm Blue Code in which hospital intensive care team
reaches the spot and provides resuscitative measures. The resuscitation may be
done in the room or the patient may be shifted to the ICU. During this
emergency, the treating primary doctor/s may or may not be there. Certain
life threatening emergency procedures may be done at that moment.
50)
I understand that there are certain unforeseen accidents
which may occur in the hospital premises in spite of the precautions. These may
include burn while taking steam, ECG electrode burn, electric monitor burn,
fall from the bed, etc. etc.
51)
I understand that it is my responsibility to disclose about
any drug allergy at the time of admission. I also understand that there may
still be some drugs to whom I may be allergic and that may end up with drug
reaction. Every unforeseen drug reaction carries a theoretical risk of
mortality and morbidity.
52)
I am/am not suffering from HIV, Hepatitis B and C positive.
53)
I am/am not suffering from open Tuberculosis.
54)
I understand that I need to declare if I have been treated
by a quake in the recent past.
55)
I understand I need to disclose if I am on Ayurvedic,
Homeopathic, Unani or drugs from other traditional healers.
56)
I have disclosed my smoking status (smoker/non-smoker)
57)
I have disclosed my alcohol intake (yes/no)
58)
I do understand that smokers may carry high mortality and
morbidity when treated and their response to treatment may be poor.
59)
It is my duty to disclose my past vaccination status and I
have understood about my future vaccination suggestions.
60)
I understand that the hospital has a policy to examine any
female patient in the presence of a female attendant or in the presence of the
husband/father.
61)
While doing an ECG, X-ray or Echocardiogram, it may be
possible that a male technician or the male doctor does the same in the
presence of a female attendant. I hereby permit for the same.
62)
I understand that when I come for a checkup, there is an
applied consent for physical and clinical examination which may involve
examination of all parts of the body if clinically indicated
63)
I understand that there are 5% chances of acquiring new
infection in the hospital premises by me or my relations/friends visiting
me. Getting hospital acquired infection/s in spite of precautions may not
mean a medical negligence on the part of the treating doctors.
64)
Even after taking all the care, it is still possible to
develop bed sore during the hospital stay depending upon my nutritional status
and immunity of the patent.
65)
I understand that ward boys and safai karamcharis may not be
available in the ward all the time. These services are provided by the
hospital and not by treating consultant/s. In case there is any delay in
any such services, I may need to contact the floor manager to sort out the same.
66)
I understand that primary treating consultant/s will see me
twice a day. They are allowed to see me once more if the situation arises for
which my treating doctor/s will be entitled for one more consultation. My
treating doctors therefore are allowed two routine and one extra emergency
consultation in a day. On the day of admission and on the day of
discharge two consultations may be charged. Even a telephonic emergency
consultation at odd hours is counted as a valid emergency visit as it involves
change in medical treatment.
67)
I understand that there is no Do Not Resuscitate Policy in
India. It is my duty to follow the legal obligations regarding end of
life issues.
68)
I understand that it is my right to get a refund of unused
medicine and disposables at the time of discharge.
69)
I understand that
difference of opinion and error of judgment is not negligence.
70)
I understand that deviation from normal practice is not
negligence.
71)
I understand that medical accidents are known to occur and
does not amount to negligence..
72)
I understand that to error is human. I understand that
I have the right to choose my consultants.
73)
I understand that at the time of discharge I will be given a
copy of detailed discharge summary for my future records.
74)
At the time of discharge I will be given radiological films,
ECGs etc. However, in medico-legal cases, this may be the property of the
hospital for legal purposes.
75)
In an unforeseen situation like death I give/do not give
permission to the hospital to initiate the process of an autopsy.
76)
I understand that the honorary treating doctors bill their
professional fee from the doctors through the hospital and the same reflects
clearly in the bill. The fee includes hospital service charges for
providing infra- structure for admitting the patients. All other charges are
billed by the hospital and belong to them. There is no system in which
primary treating consultant get any cut or commission for admitting their
patients in the hospital. The billing is transparent and fee charged by
the doctors is transparently reflected in the bill.
77)
For certain facilities not available in the hospital,
hospital may get these investigations done form empanelled diagnostic centres.
the billing for the same is done by the hospital. For these services hospital
charges may include some extra service charges.
78)
For drugs and devices not available in the hospital, for
procuring them from outside the hospital may include some extra service
charges.
79)
It may be possible that the hospital may provide
devices/implants at a higher costs than their purchase price as the
Indian Government does not have an MRP on these items. The hospital may charge
more to cover the cost of expiry, inventory, accidental fall, etc. The
treating consultant does not get any money out of these.
80)
I have been made to understand that medi-claim does not mean
100% cashless facility. They may deny 10% of the cases and ask to pay the
bill and then get it reimbursed later.
81)
I understand that Delhi medical Council does not allow
doctors to provide a medical certificate for more than 15 days without a
medical reason. The hospital may charge money for issuing a
certificate and the certificate is not valid without counter sign of the
medical administrator and the patient.
82)
I understand that at the time of death the hospital has
provisions for cold mortuary on chargeable basis.
83)
I have been made to understand about the following;
a)
Provisional diagnosis
b)
Expected duration of stay
c)
Expected approximate hospital bill (the bill may increase if
the hospital diagnose changes)
d)
Possible complications.
e)
Waiting time for my reports
84)
In an unforeseen situation like death the hospital may ask
to clear the bill before the death certificate is released.
85)
At any stage, if I am dissatisfied with services of the
hospital I need to inform the treating doctors/administration the same and not
at the time of settling the bill.
86)
I understand the hospital bill does not cover the follow up
visits for which I may be billed separately
87)
Hospital bills are computerized and may have computer
errors. Its my duty to cross check the bill and get it sorted out with the
billing department.
88)
Its my duty to sign the bill and the discharge tickets at
the time of discharge.
89)
I may be asked to
separately sign specific consents forms in addition for example for any
surgical procedure
90)
I understand that with permission I am allowed to call my
family doctor to discuss the case with the treating doctors.
91)
That If I need a private nurse I need to tale from the
hospital route.
92)
That if I need an ambulance I need to tale from the hospital
route.
93)
I understand the split ACs are more source if infections
than window ACs
94)
I understand that cross infections may occur in intensive
care units
95)
I understand that I may be billed for disposable sheets,
disposable gowns, disposable working gloves etc.
96)
I understand that the hospital follows privacy policy and
any information given by me is not disclosed to any other person without my
permission.
97)
In an unforeseen situation if I end up unconscious,
paralyzed or I am not in a position to give a consent or specific consent or
statement I hereby authorize __________________________ to give consent and
take all decisions on my behalf.
98)
I hereby authorize __________ to be briefed about me in
routine/emergency situation.
99)
I have declared my past history: diabetes (___ years),
hypertension (___ years), asthma (___ years), abnormal lipid (___
years), COPD (___ years), cancer (___ years), heart blockages (___
years), paralysis (___ years), depression (___ years), acidity (___ years),
and ________________________________.
Signature of Patient:
Signature of Spouse:
Signature of Others:
Signature of Consultant(s):
