Who May Consent The determination of who has authority to consent to medical treatment is based on an evaluation of the competency of the patient. If competent, usually the patient alone has the authority to consent. Competency refers to the ability to understand the nature and consequences of one’s decisions. In the absence of contrary evidence, it may be assumed that the patient presenting for treatment is competent. If the patient is i n c o m p e t e n t , e i t h e r b y r e a s o n o f s t a t u t o r y incompetence (e.g., a minor) or by reason of a physical or mental impairment, the inquiry must turn to whoever has the legal capacity to consent on behalf of the patient. Parents and guardians will usually have the authority to consent for their minor child or children. In many states, though not all, a husband or wife may give consent for an incompetent spouse. It is the law of the state in which the hospital is located that controls the question of “substitute consent.” Forms of Consent Consent for medical treatment should be obtained through an open discussion between the provider and patient during which the patient expressly agrees to the procedure. The consent should then be documented by having the patient sign any appropriate forms and by the provider noting any important details of the discussion in the medical record. In certain limited circumstances, the consent of an individual to simple medical treatment may be implied from the circumstances. Implied consent arises by reasonable inference from the conduct of the patient or the individual authorized to consent for the patient. Reliance on this form of consent is strongly discouraged except in the most routine, risk-free examinations and procedures. Witness to Consent Any competent adult may witness the patient’s consent. It is preferable that the witness be a staff member of the hospital who is not participating in the procedure. It is not advisable for a relative of the patient to act as a witness. Duration of Consent A consent is valid as long as there has been no material change in the circumstances between the date that consent was given and the date of the procedure. It is desirable that a new consent be obtained if there is a significant time lapse or if the patient has been discharged and readmitted due to postponement of the procedure. INCIDENT REPORTS When an event occurs that harms an individual, illustrates a potential for harm, or evidences serious dissatisfaction by patients, visitors, or staff, then a risk-management incident has taken place. Examples of such episodes could include the following:  A patient’s family helps him out of bed despite directions to the contrary by staff members. The patient falls and is injured.  Excessive silver nitrate is put into the eyes of a newborn, impairing vision.  The mother of the child complains about the care that has been given to her child and informs a staff member that she is going to talk to her lawyer about what has happened. When a member of the staff becomes aware of an incident, he has a responsibility to make the hospital command aware of the situation. The mechanism for doing this is the incident report system. Incident reports are designed to promptly document all circumstances surrounding an event, to alert the commanding officer, quality assurance coordinator, and other involved administrators and clinicians of a potential liability situation, and, in a broader sense, to establish an information base on which to monitor and evaluate the number and types of incidents that take place in the facility. Because incident reports, by their very nature, contain a great deal of information that would be of interest to persons filing claims or lawsuits against the Navy for alleged substandard medical care, and because the law recognizes the need for hospitals to have a reliable means of discovering and correcting problems, most states have enacted laws that make incident reports confidential. In other words, a person cannot obtain a copy of an incident report to help in their legal action against the hospital. However, incident reports can lose their “protected” status if they are misused or mishandled. It is important, therefore, to treat these reports like other confidential documents. You must strictly limit the number of copies made and the distribution of the reports. Do not include the report in the patient’s treatment record. The report should be limited to the facts and must not contain conclusions. Finally, the 15-9