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Communication

Explaining a procedure and gaining consent

A structured guide to explaining a simple procedure and gaining informed consent.

1. Introduction

Explaining a procedure and gaining consent requires clear communication, respect for patient autonomy and a balanced discussion of benefits, risks and alternatives.

2. Core approach

Introduce yourself, confirm the patient''s identity, establish what they already know and explain the procedure in plain language. Discuss why it is being offered, the expected benefits, the material risks, common side effects where relevant and any reasonable alternatives including doing nothing when appropriate.

3. Capacity and consent

Check understanding, answer questions and confirm that the patient has capacity for the decision and is choosing freely. Consent should be voluntary, informed and specific to the procedure.

4. Completion

Document the discussion according to local policy and ensure the patient knows what will happen next.

Opening

Explanation

Understanding

Consent