{"id":"clinical-governance-patient-consent","slug":"clinical-governance-patient-consent","title":"Clinical Governance: Patient Consent and Refusal","description":"Treatment consent, transport consent, refusal, and withdrawal all need to be visible at the point of care, not reconstructed after the event from free text. That is especially important where the case may later be review","category":"modules","tags":["modules"],"lastModified":"2026-04-17","source_ref":"content/modules/clinical-governance-patient-consent.md","url":"/developers/clinical-governance-patient-consent","htmlPath":"/developers/clinical-governance-patient-consent","jsonPath":"/api/docs/modules/clinical-governance-patient-consent","markdownPath":"/api/docs/modules/clinical-governance-patient-consent?format=markdown","checksum":"007c2eb5ccb3bce6dea70feccedba3ceb21df80e7f1666b5462047070f72c45c","headings":[{"id":"overview","text":"Overview","level":2},{"id":"key-features","text":"Key Features","level":2},{"id":"use-cases","text":"Use Cases","level":2},{"id":"integration","text":"Integration","level":2},{"id":"open-standards","text":"Open Standards","level":2}],"markdown":"# Clinical Governance: Patient Consent and Refusal\n\n## Overview\n\nTreatment consent, transport consent, refusal, and withdrawal all need to be visible at the point of care, not reconstructed after the event from free text. That is especially important where the case may later be reviewed for non-conveyance, telemedicine-supported decisions, or escalation into complaints and legal processes.\n\nThe Patient Consent and Refusal module gives the platform a structured way to capture what the patient agreed to, how consent was obtained, whether capacity concerns were relevant, and how that decision changed during the encounter. It keeps the consent record attached to the live case so clinicians, governance leads, and downstream reviewers all work from the same account.\n\n```mermaid\nflowchart TD\n    A[Encounter Starts] --> B[Consent Decision Point]\n    B --> C{Consent Outcome}\n    C -->|Treatment Accepted| D[Treatment and Transport Recorded]\n    C -->|Refusal or Non-Conveyance| E[Refusal and Capacity Record]\n    C -->|Deferred or Changed| F[Consent History Updated]\n    D --> G[Evidence or Signature Attached]\n    E --> G\n    F --> G\n    G --> H[Encounter Governance Timeline]\n    H --> I[Audit, Review, and Shared Care]\n```\n\n**Last Reviewed:** 2026-04-17\n**Last Updated:** 2026-04-17\n\n## Key Features\n\n- **Structured Consent Capture**: Record treatment consent, transport consent, refusal, and related decisions in a standard form rather than in free text alone.\n\n- **Refusal and Non-Conveyance Governance**: Make it clear when a patient declined transport or treatment and what the documented basis for that decision was.\n\n- **Capacity-Aware Documentation**: Preserve whether capacity concerns influenced the consent decision and whether escalation or representation was required.\n\n- **Consent Method and Evidence Handling**: Capture how consent was obtained, for example verbally, in writing, or through a signature workflow, with supporting artefacts where required.\n\n- **Withdrawal and Change History**: Preserve the history of consent decisions as the encounter evolves rather than overwriting earlier positions.\n\n- **Encounter-Linked Audit Trail**: Keep consent decisions attached to the case that triggered them so later review does not depend on reconstruction.\n\n- **Downstream Governance Visibility**: Let governance, complaints, and quality teams review consent context without needing a parallel record system.\n\n## Use Cases\n\n- **Treatment Consent in the Field**: A clinician records that the patient agreed to assessment and treatment before a time-critical intervention.\n\n- **Refusal to Travel**: A crew documents a patient's refusal of transport, including how the decision was explained and how the refusal was evidenced.\n\n- **Telemedicine-Supported Decision**: A remote consultation informs a consent or non-conveyance decision that remains attached to the encounter record.\n\n- **Wearable or Shared Data Approval**: A patient approves a limited data-sharing step during care and that consent remains visible to later reviewers.\n\n- **Complaint or Legal Review**: Governance teams can trace what the patient agreed to, how the decision changed, and how the final disposition was justified.\n\n## Integration\n\n- **Electronic Patient Care Report Clinical Workspace**: Consent records appear in the same clinical flow as assessment, treatment, and disposition.\n\n- **Telemedicine and Patient-Generated Data Workflows**: Consent context can support consults, wearable data retrieval, and other encounter-linked sharing journeys.\n\n- **Clinical Governance and Audit**: Reviewers can include consent completeness and refusal documentation in quality assurance work.\n\n- **Patient-Facing and Shared-Care Workflows**: When records are shared onward, the encounter carries the consent context that underpinned the original decision.\n\n## Open Standards\n\n- **HL7 FHIR R4 Consent**: consent status and scope can be represented using the standard healthcare consent resource model used across interoperable clinical systems.\n\n- **OAuth 2.0**: time-limited consent-linked access journeys can rely on a standards-based delegated authorisation pattern.\n\n- **ISO 8601**: consent, refusal, and withdrawal timestamps remain portable and machine-readable across systems.\n\n- **HTTPS / TLS**: consent data is exchanged using the standard secure web transport baseline.\n\n- **JSON**: consent records and associated workflow metadata integrate cleanly with adjacent clinical services using a structured interoperable format.\n"}