N108: Transition to the Registered Professional Nurse Role Study Guide 2.4 Legal Documents Anything that could be used in a legal proceeding can be considered a legal document. Any document that may be considered legal should be as accurate and complete as possible. It should also be completely honest. Wills Nurses should avoid witnessing wills unless it is absolutely unavoidable. The signature of the nurse on a will means that she witnessed the patient signing the will. The nurse should be sure to note the patient’s mental condition on the chart. Nurses may also be called to testify in situations where a patient’s family forged a will for a patient in a coma or in situations of abuse. Statements of Consent It is important to remember that consent is a process, not just a sheet of paper. A patient cannot truly consent unless fully informed of all risks and benefits of what he is asked to consent to allow. Express consent is done in verbal or in writing. Implied con e t can be assumed from the act of coming to a place for treatment. If the patient’s condition puts him in danger of losing life or health, implied consent can be assumed. Informed consent is used to protect patients. The risks and benefits of a procedure must be explained to the patient and the patient must give full and not coerced consent. If the patient does not have all the information, the consent cannot be considered informed. Signatures must be obtained before administering any pre-op medication to ensure that the patient is alert when consenting. Management, and possibly the surgeon, should be informed if this is not done. Informed consent contains the following information: the nature of the decision/procedure, reasonable alternatives to the proposed intervention, the relevant risks, benefits, and uncertainties related to each alternative, and assessment of patient understanding. The law places the responsibility for obtaining consent for medical treatment on the provider who will perform the procedure. The responsibility for informing the patient and obtaining his consent falls to the clinician who will do the procedure. The nurse signs as a witness to show that she saw the patient sign the paper. Additionally, the nurse has a duty to be sure the patient has all the information about the procedure. The nurse also acts as a patient advocate. If the patient asks questions after signing the consent document that implies he does not fully understand the procedure to be done, the nurse should inform the physician and supervisor. People who cannot provide consent: • Minor children require the consent of a parent or legal guardian unless the minor is married, emancipated, pregnant, a parent, or in the military. Minors may receive treatment for sexually treated diseases or obtain birth control without a parent’s consent. • A person declared mentally incompetent. • A person who is unconscious. Implied consent is assumed to treat the emergency until the person can communicate or an adult family member is available to speak for him.