We are often asked why some Ardens consultation templates have a tick box to record patient consent to an examination, whereas others don't.

Although it is hard to find guidance that refers directly to ‘examination’ and not treatment/procedure, the following GMC guidance ‘Decision making and consent’ (November 2020) has two relevant points:

• ‘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.”
• ‘Although a patient can give consent verbally (or non-verbally) you should make sure this is recorded in their notes’ – this statement however then links to a separate area where the GMC states that “You should take a proportionate approach to the level of detail you record.”

Reflecting on both points from the GMC guidance, we have agreed that consent with regards to potentially intimate examinations should be documented. Hence the consent box is already available on various consultations where the associated examination could be considered invasive or intimate.

However, we do not consider it proportional record-keeping to document consent for every patient for a ‘quick, minimally/non-invasive intervention’ such as ear examination.

Furthermore, it is the view of the Ardens team that the tick box is a useful prompt for clinicians to ask the patient for consent to examine them. The presence of a ticked consent box alone medicolegally does not in itself prove valid consent to examination – the important factors are the quality, extent and accuracy of the information given beforehand. Again however, documentation of all this would not be considered proportionate for all routine cases and examinations.  Consent becomes even more complex in other cases concerning children or patients who may have fluctuating capacity to consent to examination and clear documentation of consent and how it was obtained (i.e. not a tick box) would be needed here.

At Ardens, our templates must always strike the balance of remaining focused, streamlined and user-friendly as well as being useful prompts for clinicians, standardising information and aiding accurate but proportionate record-keeping.

When there is new national guidance published pertaining to this decision, we would be delighted to review our templates in light of this.