Checklists & Consent Forms for Informed Choice
Many practices use checklists, which can be very useful for the client and the practice group in planning midwifery care. Generally, checklists are used in two ways. One is as a to-do list to coordinate care and ensure that nothing is missed by the midwives. The second type of checklist may be topic specific (e.g., VBAC) and provide a list of things for the midwife to discuss in the context of an informed choice discussion.
Regardless of their use, the following are important elements of providing and documenting informed choice discussions using checklists:
- Ensure that all relevant topics are included in the checklist and that the list is reviewed and amended at regular intervals to ensure its currency.
- In situations where the hospital requires written consent (e.g., Rho(d) immune globulin or other blood products), the checklist should indicate that written consent is required.
- Review any documents used with clients (e.g., consent forms, hand-outs), to ensure they can be easily understood by clients (e.g., no abbreviations, plain language).
- It can be useful for the checklist to have a place for the midwife who led the discussion or completed the action on the checklist to initial or sign and date when the discussion took place.
- If the practice wishes to use a checklist to document the content of informed discussions (instead of detailed notes in the chart), the practice groups will need to document the content of the informed choice discussion in a practice group protocol. Signing and dating the checklist would then indicate that they followed the written practice protocol and included all the agreed upon information. Even if a protocol exists, if there is discussion that includes items beyond the usual or is about a specific client situation that should be recorded in the notes.
- If there is not a written practice protocol about the content of the discussion, midwives are encouraged to document the specifics of the information shared in the client's record.