Documenting Consent

Accurate documentation protects patient rights and evidences professional accountability. Records should show not only that consent was obtained, but how. Clear notes are especially important where consent was verbal or implied, as these are harder to evidence retrospectively. Good documentation also supports continuity of care.^[2][1][3]

Recording different forms of consent

Different forms call for proportionate records:^[1][2]

• Verbal consent - record the discussion, what was explained, and the patient's response (e.g., "Explained purpose and effects of dilation drops; patient consented verbally.").^[2]
• Written consent - store the signed consent form in the patient record and note the context in which it was obtained; essential for higher-risk procedures such as refractive surgery.^[1][4]
• Implied consent - record what action demonstrated consent and that the procedure was explained (e.g., "Patient positioned at slit lamp after explanation of test, proceeded without objection.").^[2][7]

Refusals and withdrawn consent

Patients may refuse or withdraw consent at any time. Records should capture:^[1][2][5]

• Information provided about risks and alternatives.^[2][4]
• The patient's exact words where possible, reflecting their reasoning.^[2][5]
• Any advice given regarding the consequences of refusal or withdrawal.^[1][3]

This safeguards autonomy and the practitioner if concerns arise later.^[6]

Best practice for record keeping

Comprehensive notes typically include:^[1][3][2]

• The type and form of consent (implied, verbal, or written).^[1]
• Information provided-risks, benefits, and alternatives.^[2][4]
• Confirmation that the patient had capacity and made a voluntary decision.^[5]
• Details of refusals, withdrawals, or concerns about coercion.^[2][5]

Examples include noting that a patient declined dilation after risks were explained, or that a referral for glaucoma was accepted following a clear explanation of urgency. Such records demonstrate compliance with GOC Standard 3, provide clarity for colleagues, and keep patient decisions central throughout the care pathway.^[1]

References (numbered in text) Why we include references

1. Annex 1 — Consent; General Optical Council Find (opens in a new tab)
2. Decision making and consent; General Medical Council (came into effect 9 November 2020) Find (opens in a new tab)
3. Records Management Code of Practice; NHS England Find (opens in a new tab)
4. Reference guide to consent for examination or treatment (second edition); Department of Health and Social Care (2009) Find (opens in a new tab)
5. Mental Capacity Act Code of Practice; Office of the Public Guardian (Published 22 July 2013) Find (opens in a new tab)
6. Shared decision making; National Institute for Health and Care Excellence (NICE) Find (opens in a new tab)
7. Consent and confidential patient information; NHS Transformation Directorate Find (opens in a new tab)