Which element should be included in documenting consent?

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

Answer: (A)

Documenting consent requires a complete, traceable record that proves the person understood the information, made a clear decision, and that there is accountability for who documented it. Including the capacity assessment shows the person had the ability to decide; the actual decision states what was chosen; the date and time pin down when the decision was made; and the signature (whether the patient or a legally authorized surrogate) confirms who recorded the consent. Noting any limitations clarifies the scope, conditions, or revocation terms of the consent. This combination ensures the consent is informed, verifiable, and properly authorized.

Signing alone isn’t enough because it doesn’t show understanding or capacity. A capacity assessment alone doesn’t capture what was decided or who signed. Date and time alone don’t identify the decision maker or the decision itself.