Informed Consent Form — Hospital Procedure
One form that documents a real conversation — procedure, risks, benefits, alternatives, and the patient’s own words — not a signature obtained at the theatre door
What it is
A one-page consent form for hospital procedures that records the actual conversation — not just a signature. It documents that the patient was told the procedure name, the three most important risks, the benefits, and at least one alternative. It includes a teach-back field: the patient describes the main risk in their own words, and that description is recorded. A consent form without teach-back proves only that a form was signed — not that the patient understood anything.
Where to use it
Completed at the pre-admission clinic or at least 24 hours before the procedure — not on the ward on the morning of surgery. Taken by the surgeon or senior registrar who will perform the procedure. Filed in the patient record; copy given to patient.
ASF criterion
Evidence for: Hospital Standard 4 — Care & Treatment, criterion 4.1 (Non-Negotiable) — Consent Is Real, Not a Signature. The Monitor will ask a recently consented patient to describe the main risk in their own words. The teach-back field on this form is the written record that the question was asked and answered.
The form
| INFORMED CONSENT — HOSPITAL PROCEDURE · ASF-TOOL-CAP-01 | |
|---|---|
| Patient full name | |
| Date of birth | |
| Patient ID number | |
| Ward / bed | |
| Diagnosis | |
| 1. Procedure | |
| Procedure name | |
| Brief description for patient | |
| 2. Risks discussed (list the three most important for this patient) | |
| Risk 1 | |
| Risk 2 | |
| Risk 3 | |
| 3. Benefits discussed | |
| |
|
| 4. Alternatives discussed (include option of no treatment) | |
| Alternative 1 | |
| Alternative 2 / No treatment | |
| 5. Questions asked by patient | |
| |
|
| 6. Teach-back — Patient’s own words (mandatory) | |
| Ask: “Can you tell me in your own words what the main risk of this procedure is?” Record the patient’s answer exactly: | |
| |
|
| Understanding confirmed? | ☐ Yes ☐ No — further explanation given, re-checked: ☐ Yes |
| 7. Consent obtained | |
| Date and time of consent conversation | |
| Hours before procedure | |
| Consent given by | ☐ Patient ☐ Legal guardian (name: Relationship: ) |
| Patient / guardian signature | |
| Clinician taking consent (name + role) | |
| Clinician signature | |
| Interpreter used? | ☐ No ☐ Yes (name: ) |
| Copy given to patient: ☐ Yes Filed in patient record: ☐ Yes Right to withdraw consent explained: ☐ Yes | |
The most common mistake
Sections 1–4 completed carefully, Section 6 left blank or filled with “patient understood.” The teach-back field is the only field the Monitor cannot verify from the form alone — the patient interview is the check. If Section 6 is blank, the Monitor will ask the patient directly.
Translate and adapt
English master edition. Any facility may translate, add its logo, and adapt wording to local practice — keeping the ASF reference code, source, and licence in the footer. Georgian edition available on request. Confirmed against: WHO Safe Surgery guidelines; Georgian Law on Patient Rights (2000, amended 2015). Drug doses and clinical thresholds must be confirmed against national protocols.
ASF-TOOL-CAP-01 · Toolkit 33 — Clinical Assessment & Care Planning · france-asf.fr/tools · ASF original © Accréditation Sans Frontières · Released under CC BY-NC-SA 4.0 · Source: WHO Surgical Safety Guidelines; Georgian Law on Patient Rights 2000 · Keep this line on all adapted versions
