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Informed Consent Update – Webinar

August 6 @ 9:00 am - 11:00 am

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Ever been confused about what standards and guidelines apply to informed consent? This program will discuss the current CMS hospital Conditions of Participation (CoPs), including the critical access hospital, Joint Commission and DNV Healthcare standards on informed consent requirements. It will include some confusing CMS changes such as having a patient advocate sign the consent form when present even if the patient is competent.

It will cover the Joint Commission revised informed consent standards. This includes the requirements for discussion of recuperation.

This program will discuss standards on consent for research. Not doing this right can also cost hospitals money. A study found that consent forms were missing in 66% of patients delaying 10% of surgical procedures. The researchers at Johns Hopkins found the cost of lost of misplaced consent forms cost hospitals $580,000 a year.

Besides being a financial issue CMS, TJC, DNV Healthcare and other accreditation organizations are scrutinizing the standards. A memo by CMS showed this is a common deficiency among hospitals.

The Centers for Medicare and Medicaid Services (CMS), has three different sections in the hospital CoP manual regarding Patient Rights and Informed Consent. All hospitals that receive Medicare and Medicaid reimbursement must comply with these interpretive guidelines. This program will discuss the CMS requirements for hospitals and critical access hospitals since they are very different.

The hospital must follow the consent regulations for all patients and not just Medicare and Medicaid hospitals. Failure to follow these regulations could result in the hospital being excluded from the Medicare program.  Hospitals should ensure that their policies and procedures reflect the CMS requirements and that their staff are educated their staff on these informed consent interpretive guidelines. There are six mandatory elements and additional ones which are optional for hospitals to adopt. CMS requires the hospital to ensure that physicians are following these guidelines. Consent is a process and not just having a signed form.

Healthcare providers must also be aware of their specific state law on informed consent. Many professional organizations, like the American College of Surgeons, American Society of Anesthesiologists, and the American Association of Nurse Anesthetists also have guidelines or position statements on informed consent. Come join us for a fun session on making informed consent a little simpler to understand!


  • Recall that the CMS hospital CoP interpretive guidelines has 3 separate sections on informed consent,
  • Explain the hospitals and critical access hospitals have a separate guideline from CMS on informed consent and they are very different,
  • Describe the six minimum requirements that are now mandatory to be in the informed consent form for surgery done at a hospital that receives Medicare reimbursement including that the name of the hospital must always be on the form,
  • Discuss that there the CMS and accreditation standards applicable to your facility should be reflected in the  hospital’s policies and procedures,
  • Identify that the medical staff must have a list of procedures and tests that will require an informed consent under federal regulations.