Informed Consent Is More Than a Signature

Informed consent is often associated with forms, signatures and clinical procedures. But in general practice, consent is much broader than that.

At its core, informed consent is about communication, understanding and choice. It means the patient has been given enough information to make a decision about their care, in a way they can understand, and without pressure.

With the RACGP Standards for general practices 6th edition now released, and with continued focus on patient-centred care, communication, shared decision-making and safe systems, now is a good time for practices to think about whether their approach to consent is practical, consistent and well understood by the team.

A signed form can be useful, but it is not the whole process. In many situations, the most important part of consent is the conversation that happens before a decision is made.

Patients should understand what is being proposed, why it is recommended, what the likely benefits and risks are, what alternatives exist, and what might happen if they choose not to proceed. They should also have the opportunity to ask questions and express their preferences, concerns and goals.

For routine care, consent may be implied through a patient’s actions. For example, a patient rolling up their sleeve for a blood pressure check or attending a follow-up appointment may indicate agreement in context. But where there is greater clinical risk, complexity, cost, uncertainty or potential impact on the patient, a more deliberate discussion is needed.

Good consent processes also need to account for health literacy, language, culture, disability, distress and decision-making capacity. Some patients may need an interpreter, extra time, written information, visual aids, a support person, or a follow-up conversation before they feel able to make a decision.

This is where supported decision-making becomes important. Support should help the patient understand and communicate their wishes, not take the decision away from them.

Practices can strengthen their approach by asking:

• When do we rely on implied consent, and when do we seek express consent?
• How do we document consent discussions?
• Do our clinicians record the risks, benefits, alternatives and patient response where relevant?
• How do we support patients with communication or understanding needs?
• Are interpreters used appropriately?
• Do team members understand when consent is needed for third-party involvement, photographs, teaching, recalls, procedures or sharing information?
• Are consent forms current, accessible and easy to understand?

Informed consent is not just a legal safeguard. It is a trust-building process. When patients understand their options and feel involved in decisions, care is more likely to be respectful, person-centred and safe.

Practices do not need to overcomplicate this. A useful starting point is to review current consent forms, discuss consent scenarios at a team meeting, check documentation habits, and identify where staff may need clearer guidance.

The goal is not more paperwork. The goal is better conversations, clearer decisions and stronger evidence that patients are genuinely involved in their care.

QIP Consulting supports general practices to prepare for changing accreditation expectations in ways that are realistic and workable. Ready to strengthen your consent processes without overcomplicating them? Reach out to us https://qipconsulting.com.au/contact-us/