Louisiana Administrative Code › Title 48 - PUBLIC HEALTH-GENERAL › Part I - General Administration › Subpart 1 - General › Chapter 23 - Informed Consent › Section I-2301 - Disclosure of Risks/Patient Consent

Current through Register Vol. 50, No. 6, June 20, 2024
A. Pursuant to
				  R.S.
				  40:1299.40 E, the Louisiana Medical Disclosure
				  Panel recommends use of the following general form, or use of a substantially
				  similar form, for disclosure of risks and hazards related to medical care and
				  surgical procedures.
PATIENT CONSENT TO MEDICAL TREATMENT OR SURGICAL
					 PROCEDURE AND ACKNOWLEDGEMENT OF RECEIPT OF MEDICAL INFORMATION INFORMATION
					 ABOUT THIS DOCUMENT READ CAREFULLY BEFORE SIGNING
TO THE PATIENT: You have been told that you should
					 consider medical treatment/surgery. Louisiana law requires us to tell you (1)
					 the nature of your condition, (2) the general nature of the medical
					 treatment/surgery, (3) the risks of the proposed treatment/surgery, as defined
					 by the Louisiana Medical Disclosure Panel or as determined by your doctor, and
					 (4) reasonable therapeutic alternatives and material risks associated with such
					 alternatives.
You have the right, as a patient, to be informed about
					 your condition and the recommended surgical, medical or diagnostic procedure to
					 be used so that you may make the decision whether or not to undergo the
					 procedure after knowing the risks and hazards involved.
In keeping with the Louisiana law of informed consent, you
					 are being asked to sign a confirmation that we have discussed all these
					 matters. We have already discussed with you the common problems and risks. We
					 wish to inform you as completely as possible. Please read the form carefully.
					 Ask about anything you do not understand, and we will be pleased to explain
					 it.
1. Patient Name
_____________________________________
2. Treatment/Procedure:
(a) Description, nature of the
				  treatment/procedure:
______________________________________________________
______________________________________________________
(b) Purpose:
______________________________________________________
______________________________________________________
3. Patient Condition:
Patient's diagnosis, description of the nature of the
					 condition or ailment for which the medical treatment, surgical procedure or
					 other therapy described in Item Number 2 is indicated and recommended:
___________________________________________
___________________________________________
4. Material Risks of Treatment
				  Procedure:
(a) All medical or surgical
				  treatment involves risks. Listed below are those risks associated with this
				  procedure that we believe a reasonable person in your (the patient's) position
				  would likely consider significant when deciding whether to have or forego the
				  proposed therapy. Please ask your physician if you would like additional
				  information regarding the nature or consequences of these risks, their
				  likelihood of occurrence, or other associated risks that you might consider
				  significant but may not be listed below.
[ ] See attachment for risks identified by the Louisiana
					 Medical Disclosure Panel
[ ] See attachment for risks determined by your
					 doctor
(b) Additional risks
				  (if any) particular to the patient because of a complicating medical condition
				  are:
____________________________________________________
_____________________________________________________
(c) Risks generally associated with any
				  surgical treatment/procedure, including anesthesia are: death, brain damage,
				  disfiguring scars, quadriplegia (paralysis from neck down), paraplegia
				  (paralysis from waist down), the loss or loss of function of any organ or limb,
				  infection, bleeding, and pain.
5.
Reasonable therapeutic alternatives
				  and the risks associated with such alternatives are:
___________________________________________________
___________________________________________________
ACKNOWLEDGMENT
AUTHORIZATION AND CONSENT
6.
(a)
No Guarantees
: All information given me and, in particular, all
				  estimates made as to the likelihood of occurrence of risks of this or alternate
				  procedures or as to the prospects of success, are made in the best professional
				  judgment of my physician. The possibility and nature of complications cannot
				  always be accurately anticipated and, therefore, there is and can be no
				  guarantee, either express or implied, as to the success or other results of the
				  medical treatment or surgical procedure.
(b)
Additional Information
:
				  Nothing has been said to me, no information has been given to me, and I have
				  not relied upon any information that is inconsistent with the information set
				  forth in this document.
(c)
Particular Concerns:
I have had an opportunity to disclose to and
				  discuss with the physician providing such information, those risks or other
				  potential consequences of the medical treatment or surgical procedure that are
				  of particular concern to me.
(d)
Questions:
I have had an opportunity to ask, and I have asked, any
				  questions I may have about the information in this document and any other
				  questions I have about the proposed treatment or procedure, and all such
				  questions were answered in a satisfactory manner.
(e)
Authorized Physician:
The
				  physician (or physician group) authorized to administer or perform the medical
				  treatment, surgical procedures or other therapy described in Item 2 is:
__________________________________
(Name of authorized physician or group)
(f) Physician Certification: I hereby certify
				  that I have provided and explained the information set forth herein, including
				  any attachment, and answered all questions of the patient, or the patient's
				  representative, concerning the medical treatment or surgical procedure, to the
				  best of my knowledge and ability.
_________________________________________________________
(Signature of Physician) Date Time
CONSENT
Consent
: I hereby authorize and direct the
					 designated authorized physician/group, together with associates and assistants
					 of his choice, to administer or perform the medical treatment or surgical
					 procedure described in item 2 of this Consent Form, including any additional
					 procedures or services as they may deem necessary or reasonable, including the
					 administration of any general or regional anesthetic agent, x-ray or other
					 radiological services, laboratory services, and the disposal of any tissue
					 removed during a diagnostic or surgical procedure, and I hereby consent
					 thereto.
I have read and understand all information set forth in
					 this document, including any attachment, and all blanks were filled in prior to
					 my signing. This authorization for and consent to medical treatment or surgical
					 procedure is and shall remain valid until revoked.
I acknowledge that I have had the opportunity to ask any
					 questions about the contemplated medical procedure or surgical procedure
					 described in Item 2 of this consent form, including risks and alternatives, and
					 acknowledge that my questions have been answered to my satisfaction.
________________________________________________________
Witness
_________________________________________________________
Patient or Person Authorized to Consent Date/Time
___________________________________
Relationship
If consent is signed by someone other than the patient,
					 state the reason:
_______________________________________________________
_______________________________________________________
Attachment to Consent to Medical Treatment or
					 Surgical Procedure and Acknowledgment of Receipt of Medical Information
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Patient's Signature Date/Time