Health Information Management Consent Process

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Team ID: 
College / Administrative Unit: 
Student Affairs
Date Started: 
October 2008
To evaluate the documentation of the informed consent process in comparison to benchmarks of UHS policies and federal regulations. Health records will be analyzed for timely scanning of the paper consents into the electronic health record, correct consent type and completion of all fields on the consent and other required documentation of the process. The goal is 100% compliance.

Three months of records containing consents were reviewed in late 2008, early 2009. Compliance is high for the correct consent type and timely scanning into the electronic health record.
The review identified some specific areas for improvement in completion of all form fields and associated documentation. The team is collaborating with Clinical Services to identify potential corrective actions, such as electronic health record enhancements, to improve process compliance.


Data was collected from August, September and October 2009; 112 consents were reviewed. The analysis of these 112 consents was based on three areas on the form.
The goal was to have 100% compliance and the previous project revealed 50%. With the new form, compliance is at 79%.
The following corrective actions were taken:
1) reviewed findings with the Clinical Director and Clinical Services
2) the boxes on the form are now bigger and bolded and placed next to the patient and counselor’s signature
3) Clinical Services staff trained in form use

Remeasurement will be made in late spring of 2010.

November 10, 2011

2011 data collection was February through April 2011.Our performance goals of 100% on all consents were not achieved.
HIM, Medical Staff and Risk Management are reviewing Policy XIII.36 to ensure that our practice and documentation matches current policy.

We will collect data again from this Fall semester, 2011, to report in February 2012.

Nancy Lambert

Contact Person: 
Nancy Lambert
  • Nancy Nolf, Leader
  • Lorianne Bressler, Member
  • Rita Carpenter, Member
  • Cheryl McCloskey, Member
  • Heather Miles, Member
  • Lisa Witt, Member