reviewing health status and granting waivers for
those individuals unable to safely participate in
physical fitness testing and training, and
assisting in the development of exercise
LEGAL IMPLICATIONS IN MEDICAL
LEARNING OBJECTIVE: Recognize the
policies and procedures pertaining to
consent for medical treatment, incident
reports, and release of medical information.
There are few aspects of medical administration of
treatment that do not have some legal implications.
Every time a patient comes into contact with a facility
or its staff members, either directly or indirectly,
formally or informally, the potential for legal
entanglement exists. Although the law has become
more and more involved in the operation of hospitals,
the exercise of common sense combined with a
knowledge of those situations that require special care
will protect the hospital and its staff from most
This section addresses some of the situations that
regularly arise and have legal consequences, including
the policy and instructions that apply to those
situations. Keep in mind that the law is an inexact
science, subject to widely varying circumstances. The
information in this chapter cannot substitute for the
advice of an attorney.
Hospital staff members are
encouraged to consult with hospital or area Judge
Advocate General (JAG) Corps officers on issues with
which they are uncomfortable.
CONSENT REQUIREMENTS FOR
With limited exceptions, every person has the right
not to be touched without his having first given
permission. This right to be touched only when and in
the manner authorized is the foundation of the
requirement that consent must be obtained before
medical treatment is initiated.
Failure to obtain
consent may result in the healthcare provider being
responsible for an assault and battery upon the patient.
While the term consent in the medical setting
refers to a patients expressed or implied agreement to
submit to an examination or treatment, the doctrine of
informed consent requires that the healthcare
provider give the patient all the information necessary
for a knowledgeable decision on the proposed
procedure. When courts say that a patients consent
must be informed, they are saying that a patients
agreement to a medical procedure must be made with
full awareness of the consequences of the agreement.
If there is no such awareness, there has been no lawful
The duty to inform and explain rests with the
provider. THIS RESPONSIBILITY CANNOT BE
The provider must describe the proposed
procedure in lay terms so the patient understands the
nature of what is proposed. The risks of the treatment
must be explained. If there are any alternative medical
options, they should be disclosed and discussed.
For common medical procedures that are
considered simple and essentially risk free, a provider
is not required to explain consequences that are
generally understood to be remote. A determination of
what is simple and common should be made from the
perspective of appropriate medical standards. Where
the harm that could result is serious or the risk or harm
is high, the duty to disclose is greater.
Methods should be developed within each hospital
department to acquaint patients with the benefits,
risks, and alternatives to the proposed treatment. In
some departments, prepared pamphlets or information
s h e e t s m a y b e d e s i r a b l e .
I n o t h e r s , o r a l
communication may be the best method. Some states
(e.g., Texas) have laws that are very specific about
what is required.
Consent before treatment is not necessary when
treatment appears to be immediately required to
prevent deterioration or aggravation of a patients
condition, especially in life-threatening situations, and
it is not possible to obtain a valid consent from the
patient or a person authorized to consent for the
patient. The existence and scope of the emergency
should be adequately documented.