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There are 4 components of informed consent including decision capacity, documentation of consent, disclosure, and competency. Doctors will give you information about a particular treatment or test in order for you to decide whether or not you wish to undergo a treatment or test.
The Joint Commission requires documentation of all the elements of informed consent in a form, progress notes or elsewhere in the record. The following are the required elements for documentation of the informed consent discussion: (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3)
The consent form must include: A statement that the study involves research. Purpose of the research. Procedures. Risks or discomforts to the subject. Benefits of the research to the subject. Treatment Alternatives. Costs of Participation. Confidentiality.
Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing. The CARE guidelines recommend obtaining informed consent AND the patients perspective on the treatment/outcome (if possible).
I freely agree to participate in this case report as described, and understand that I am free to withdraw my consent at any time before publication. I understand that once the case report is written and published, it will not be possible to have the information recalled or deleted.
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The informed consent documentation should be friendly, straightforward, and conversational. Ideally, the adult informed consent documents should be written at or below an 8th grade reading level, with a readability score of more than 50 (the higher the score, the easier your document is to read).
I have read and I understand the provided information and have had the opportunity to ask questions. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost. I understand that I will be given a copy of this consent form.

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