Item | Response | Points |
Description of procedure | ||
1) Is language describing what the procedure is (beyond the medical name) provided for the patient? | ‘Yes’ | 2 |
‘No’ | 0 | |
1a) If provided, is it typed? | ‘Yes’ | 1 |
‘No’ | 0 | |
‘N/A’ | 0 | |
2) Is a description of how the procedure will be performed provided for the patient? | ‘Yes’ | 2 |
‘No’ | 0 | |
2a) If provided, is it typed? | ‘Yes’ | 1 |
‘No’ | 0 | |
‘N/A’ | 0 | |
Rational for procedure | ||
3) Is the clinical rationale (condition-specific justification) for why the procedure will be performed provided? | ‘Yes, full criteria met’ | 2 |
‘Partly’ | 1 | |
‘No’ | 0 | |
Patient-oriented benefit(s) | ||
4) Is any patient-oriented benefit provided (intended impact on patient's health, longevity, and/or quality of life)? | ‘Yes’ | 2 |
‘No’ | 0 | |
Probability of procedure-specific risks | ||
5) Is a quantitative probability provided for any procedure-specific risk? | ‘Yes’ | 2 |
‘No’ | 0 | |
6) Is a qualitative probability provided for any procedure-specific risk? | ‘Yes’ | 1 |
‘No’ | 0 | |
Alternative(s) to the procedures | ||
7) Is any alternative provided for the patient? | ‘Yes’ | 2 |
‘No’ | 0 | |
Timing | ||
8 (a) Date document was shared with patient (if not available, date of patient's/proxy's signature) 8 (b) Date of procedure 8 (c) Patient opted out of receiving the consent document at least 1 day prior to the procedure | At least one calendar day before procedure OR patient opted out | 5 |
Same day as procedure | 0 | |
Missing either date of patients’/proxy’s signature or missing date of procedure | 0 | |
Maximum quality score | 20 |
N/A, not applicable.