**This is an old revision of the document!**

1. RECOMMENDED CONTENTS OF CONSENT FORM-INFORMATION INCLUDED IN CONSENT FORM

  • A separate, standard consent form for PHIE entitled “Consent for Participation to PHIE” shall be developed by health facilities. The consent form must be clear, simple, and have a local translation which the patient can understand. Within its contents there shall be an opt-out clause, a list of information to be gathered for shared purpose, date and time the consent was given, contact number of the patient or legal representative, and a provision stating that the patient's identity will be protected. Upon obtaining consent, the patient shall affix his/her printed name below the Patient Admission Form. If consent was denied, a refusal form shall be provided.
  • The consent form shall take into the decision of the deceased patient's family members regarding organ donation.

2. MANNER OF OBTAINING CONSENT

  • The consent procedure must adequately inform patients about the choices they have and the consequences of their choices, and the procedure must be conducted in a manner that ensures that consent is entirely voluntary.

a. Who shall consent-who shall consent and exceptions-form of consent

  • For patients who are physically or mentally incapable of giving consent, the persons authorized to sign the consent in their behalf are:

a. Immediate relatives within the 3rd degree of consanguinity based from hierarchy;
b. Cohabitant partner for a minimum of 1 year or identified guardian;;
c. Social worker; d. Persons with special power of attorney.

  • For unconscious and minor patients, consent shall be given either by the parents, spouse (if married), descendant, ascendant, and/or guardian. The family's decision may also be obtained by the physician.
  • For unconscious patients with no relative upon admission, the doctor can decide on his/her behalf.
  • In emergency situations, significant others can sign the consent however, the consent for sharing information in PHIE is not applicable.

When will consent be obtained

  • Consent for the PHIE shall be obtained upon admission but if the patient does not give consent upon admission or is in an emergency case, efforts should be made to obtain consent upon discharge. To avoid missing consent, a system may be developed to indicate completion of consent taking. Viable occasions to obtain consent: admission, admitting order, discharge.
  • Case Exemptions.
    For national security purpose, the following situations do not need consent for information to be processed in the PHIE:
    a. Emerging diseases identified in R.A. 3573.

Who will obtain consent

  • A designated staff, not necessarily a doctor, shall obtain the consent for PHIE.

VALIDITY OF CONSENT
For consent to be considered valid, it must contain all of these 5 elements: Disclosure- the consenter has the information needed to make an autonomous decision, Capacity or Competence- the consenter's ability to understand the information to make judgments about the potential consequences of his or her decision, Understanding or Comprehension- the consenter's comprehension of the information provided, Voluntariness- the consenter's right to make a decision freely without external pressure or coercion, and Consent or Decision- the consenter's authorization for PHIE.

Acceptable forms of obtaining consent.

  • A thumb mark may be considered once the consenting patient is incapable to imprint his signature but must be witnessed by a person of legal age.

Provisions on duration of validity.

  • Health care providers shall comply with the medical records requirements electronically. OPD: 5 years, In-patient:10-15 years, Medico-legal cases: lifetime.

Provisions on revoking or reinstating consent.

  • A valid court order shall prevail over written consent.
  • For unconscious and minor patients, when the patient becomes able (becomes conscious and is of legal age), he/she may revoke the consent previously give by their authorized representative.

4. OTHER PROVISIONS, CAPACITY BUILDING, INFORMATION DISSEMINATION, OTHERS…

  • DOH shall enforce an information drive regarding the PHIE consent in public and private facilities as well as other health centers.
  • The social worker will prepare a clinical case study on the physically or mentally incapable patient who cannot give consent in time of health need.
  • Triage personnel must be oriented regarding PHIE and consent form for data collection.
  • Religious and cultural beliefs shall be included in the patient's basic information to avoid complications in the management and treatment of patient.
  • In order to reduce errors, please provide a standard case definition for the following:

a. OPD
b. Emergency
c. In-patient
d. Referred patient for laboratory and radiology procedures and other services

  • Outpatient- a patient who receives healthcare services without being admitted for inpatient medical care or healthcare services and does not occupy a bed for any length of time; or a patient who consults and receives healthcare services in the healthcare facility without being admitted.
  • Emergency- unforeseen combination of circumstances which calls for immediate life-preserving or quality-of-life preserving actions (to preserve sight in one or both eyes, hearing in one or both ears, extremities at or above the ankle or wrist).
  • Inpatient- a patient admitted in the hospital receiving healthcare services and who is provided room, board and continuous nursing services in a unit area of the healthcare facility.

References:

  • Department of Health, NCHFD. (2010). Hospital Health Information Management Manual 3rd Edition, Manila, PH: Department of Health
  • Hosek S., Straus S. (2013). Patient Privacy, Consent and Identity Management in Health Information Exchange. Issues for the Military Health System. Santa Monica, CA: RAND Corporation.

See Also