Delegated Consent:
Procedure-Specific Training and Competency Record (Form 1)
Surname: / Forename: /Title (Mr, Ms, Dr)
/ Payroll No: /Directorate:
Healthcare professionals must not take delegated consent for any procedure until they have had general principles of consent training, and procedure-specific training.
Date of principles of consent training:
/ Date of procedure-specific training:OPERATION / PROCEDURE(S)
Self-assessment by healthcare professional:
1. I have an awareness and understanding of the Trust’s consent policy
2. I understand the risks associated with this procedure
3. I understand the benefits to this procedure
4. I understand the alternatives to this procedure
5. I have the ability to explain this procedure to a patient
6. I know where to seek advice if required
7. I know where to obtain patient information in relation to this procedure
8. I have the ability to explain the after care for this procedure
9. I know where the patient can seek further information if required
10.I know how to record the discussion using appropriate documentation according to policy
Statement: I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. I am competent to take consent for the procedure(s) stated above
Signature: Date:
The practitioner named above has received specific training in the above procedure(s). S/he had demonstrated knowledge and understanding of the procedure(s) and demonstrates appropriate attitudes and behaviour when discussing these issues with patients. I am therefore satisfied that s/he is able to take delegated consent from patients in the procedure(s) listed above.
Signature of consultant / supervisor: Date:
This / these procedure(s) must now be entered on the clinician’s training and competency log – form 2
When completed, a copy of this form should be sent to Clinical Governance Assistant, and the original retained in the health professional’s portfolio