How do you document consent?

• A. Note capacity assessment, decision, date/time, and the person’s or surrogate’s signature; include any limitations
• B. Just sign
• C. Document capacity only
• D. Document only the date

Answer: (A)

The essential idea is that consent must be documented with enough detail to prove the patient’s voluntary, informed choice. That means showing a capacity assessment was made and found the person able to understand the information, appreciate the risks and benefits, reason about options, and communicate a clear decision. You then record the specific decision or procedure the patient agreed to, the exact date and time the consent was given, and the signature of the patient or the legally authorized surrogate who provided it. If a surrogate is involved, note their relationship to the patient and their authority to consent. Any limitations or conditions attached to the consent should be documented as well, such as conditions the patient set, refusals, or scope limits of what was approved. This combination—capacity status, the actual decision, when it was made, who signed, who approved on the patient’s behalf, and any stated limits—creates a complete, auditable record that the consent was informed, voluntary, and legally valid. Merely signing, or recording only a date or only capacity, does not provide the full, accountable picture needed for proper consent documentation.