Where possible, it is desirable for the informed consent discussion to occur a sufficient period of time before the proposed procedure or treatment in order to allow the patient time to consider the information and ask questions.

During the discussion, it is recommended that the physician use language the patient can understand and avoid the use of "medical jargon."

The informed consent discussion may take place in the physician's office prior the patient's hospital admission, in the patient's hospital room, and in emergent situations, in the emergency room or other procedure/treatment areas of the hospital.

A patient must have capacity in order to give informed consent.
This requires that the patient understand the proposed procedure or treatment and be able to voluntarily give or withhold his or her consent after making an informed decision.
Informed consent may be given by adult patients with capacity, the parent or legal guardian of a minor, emancipated minors under specific circumstances or a court or patient designated surrogate of a patient without capacity. In some instances, a family surrogate may give consent.

The following information should be discussed with the patient and documented in the medical record:

  1. The nature of the patient's illness, the diagnosis, the proposed treatment plan and the prognosis.
  2. A description of the recommended procedure or treatment, and its purpose.
  3. The probable outcome particularly if it is difficult to predict, and the patient's expected post-procedure/treatment course.
  4. The most likely risks and side-effects, the potential benefits, as well as the potential complications of the procedure or treatment. (see below)
  5. Reasonable alternative methods of treatment or non-treatment including the risks, benefits, complications, and prognosis associated with each alternative or with non-treatment.
As a general rule, a physician is required to disclose information to a patient that a reasonably prudent person under similar circumstances would want to know.

A physician need not disclose all of the risks or complications which may occur, but should discuss:
1) those commonly associated with the procedure or treatment and having a reasonable chance of occurring; and
2) those which have a large chance of occurring, but which have grave consequences.
Less common or remote risks/complications should be discussed with the patient if they are significant to that patient.