Sign A Consent Without Witnessing Actual Signature

Nurses General Nursing

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So I work at a surgeon's office as my main job. One of the duties we have (the LPNs and MAs) is signing the surgical consent forms as witnesses.

After we room the patient, we fill out some basic stuff on the form and leave it for the provider. Usually the providers are good about holding off on signing the consent until they can track one of us down to witness.

I don't know what the protocol was before I came to the office as I started at the beginning of this year, but I've had a surgeon not come get me when he and the patient signed the consent form. He just hands me the signed form and apparently expects me to sign it as a witness.

I will not sign the consent form unless I have heard the provider going over the risks benefits and/or physically seen the patient sign the form.

Every time I have brought this up with my MA coworkers, they seem to think writing "to sig only" after my name puts me in the clear.

Would you guys sign a consent form that you physically did not witness being signed?

One of the problems with compromising on stuff like this is that it always morphs over time via interpretations and misunderstandings that are passed on person-to-person.

Frequently, this consent issue morphs to the point that no one has talked about anything and yet the form is being signed and witnessed. Nurses have a great tendency to conflate signing the form with obtaining the consent. The two are not the same. The person performing a procedure is (generally) the one who can/should obtain a legal consent. The form is separate, and is merely an attestation by the patient that they have had the conversation, understand what's going to happen and why, and have indeed given consent.

If I wasn't present for the consent conversation, then the only thing I could possibly be attesting to/witnessing is the signature itself. So no I would not be signing if I hadn't witnessed it.

If you're ever aware of a situation where things aren't quite as they should be, you will learn to be prickly about this. If you're working in a situation where you are expected to have all forms signed when literally no one to be involved in the procedure has met the patient, you will learn to be prickly about this. I have successfully put my foot down about this very thing. It's not okay. In many instances, the nurse making sure this is done correctly is THE one and only stop-gap. For instance, if I agree to have patients sign things because someone upstairs plans to talk to them about something, I have just foiled the entire process of making sure that it actually happens. I get sick of people going along with stuff like this.

We are there for patients.

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Not exactly. You are assessing your patient, for whether or not they consent to the surgery. You are not assessing the doctor for whether or not he explained the surgery.

My point was: isn't the best way to assess if the patient understands the procedure, barring asking them, to be present in the room while the provider explains everything? I guess if you can't actually be in the room for the explanation, asking the patient if they had all their questions answered is the way to go.

I really appreciate your advice, Folks. It has helped me a lot. We have a meeting between the clinical staff here (two LPNs including me, two MAs, and our manager) and I want to talk about consents to them: how have they been doing them, the legal aspects, how do they ensure the patient actually understands the procedure/surgery (if they actually do).

Heck, maybe that's why they write "to sig only" underneath the witness line; because they are saying they witnessed the signature but did not follow up to ensure the patient understands the surgery/procedure.

Again, thanks for the good advice and please keep it up!

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Specializes in ED, ICU, PSYCH, PP, CEN.

Even if you are in the room when the doctor talks to the patient about the procedure (and does it well) there is no guarantee that the patient understands what he said. Let us know how your meeting goes because this is a common problem that I have encountered in many different settings.

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I will let y'all know how the meeting goes and what conclusions we came to!

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Specializes in Med/Surg/Infection Control/Geriatrics.
Is there any reason that the surgeon cannot sign as a witness?

I was taught by a legal consultant that consenting is actually a provider owned process. The papers we have patients sign do not mean much legally.

There would be a conflict of interest if it was he/she who was about to do the surgery.

Witness means just that. Witness. If you did not witness it, don't sign it.

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Would you guys sign a consent form that you physically did not witness being signed?

I can, and do, all the time. At least once a month. As a witness you are merely documenting that a conversation occurred. Every facility I have had includes a list of questions to go through with the patient/family if you do not physically see/hear the conversation. If I am with a provider while they explain a procedure, I do not ask the questions but do ask the patient and family if ALL of their questions have been answered. If I do not see that conversation, I ask the questions. Our consent for procedure includes about 5 questions which, if the provider did a good job with the conversation, patients/families answer very easily and quickly. If not, I ask the provider to come back and discuss with the family again.

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I am skeptical of the varied interpretations of "witness" expressed here.

As far as I can tell, a consent is a legal document. I posted a link to a legal definition, which in essence requires a witness to witness what they are witnessing.

Does anybody have a source that states that a witness does not have to see the event, but has to ensure understanding? Or that in a hospital, the term "witness" has a different definition than it does in the law, or in the English language?

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There would be a conflict of interest if it was he/she who was about to do the surgery.

Witness means just that. Witness. If you did not witness it, don't sign it.

1. Yes, surgeons cannot usually sign the consent form in a place other than "provider signature". We have some old (before go live with our current EMR) consent forms floating around where the provider signed on the sheet too. Now the attendings have to "sign" a note in the EMR.

2. Surgeons and/or anesthesiologists will sign consent forms in lieu of a patient/their family. They can and do this in most cases - this is part of many the process for handling a life threatening emergency in many facilities. They usually sign the forms AFTER surgery, but legally two physicians can sign.

3. Witnessing it means that you either saw the conversation or believe it occurred. Many facilities have a list of questions on their consents for staff to ask patients/families if they do not see/hear/otherwise observe the conversation. These questions help you understand if the conversation occurred and identify possible questions.

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I am skeptical of the varied interpretations of "witness" expressed here.

As far as I can tell, a consent is a legal document. I posted a link to a legal definition, which in essence requires a witness to witness what they are witnessing.

Does anybody have a source that states that a witness does not have to see the event, but has to ensure understanding? Or that in a hospital, the term "witness" has a different definition than it does in the law, or in the English language?

It is usually defined by the hospital/health care system. It may even have something to do with legal requirements and practice acts/regulations in a given state.

However, I witness consents for cases I did not see/hear/otherwise observe the conversation explaining the procedure all the time. Our facility's surgery/procedure consent explains the witness section as "having observed" or "having assessed the following questions (and spells them out)"

Our questions ask about the procedure (site, plan, etc), whether residents/other trainees might be involved, were risks/benefits discussed, did/do you give permission for the procedure, were your questions answered, do you have additional questions, etc.

They *do not* have to be able to use our words to describe their procedure. They have to identify site, plan, etc. As in, on a consent where the provider writes "right craniectomy for resection of mass" the patient/family/guardian may say "taking tumor out" when asked about where they may say "my head", and then I generally ask them to tell or point to the correct side.

Most people do not understand things the way physicians and nurses do. The vocabulary is too complex, too much is going on. I meet people sometimes on the worst days of their lives.

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I will agree with others who have suggested that this is probably NOT an appropriate MA task. HOWEVER, I will remind you that MAs are not technically from a legal/practice standpoint, supervised by an RN. They are supervised by the physician(s) they work with.

I'm an OR nurse. Unless a situation is life threateningly emergent and there are not family members present to provide verbal or written consent, I am expected to "check" for consent. Obviously, I am not going to hold up a truly emergent procedure over paperwork. In MOST states, consent for emergency treatment (including blood/blood products and treatment of minors) is presumed/assumed. A NICU baby flown up from a smaller hospital who needs an ex-lap is going to get it, whether or not we can contact Mom, Dad, Grandparents, the county (whoever the legal decision maker is). A teenager in a car accident is getting treated without consent, provides the procedure is life or limb threatening. A little old lady or gent who has a massive subdural is going to have surgery before we know their family wouldn't otherwise consent. People get blood products (all the time) due to emergent need and lack of knowledge that they would decline administration of the products.

It is on the list of paperwork I go through, and through my discussions with patients/families, I can generally easily discern whether they understand (even on their level which is not likely my level or the surgeon's level) what the plan is. If they have questions, I won't sign the form before asking the surgeon to have an additional discussion with the patient/family.

I think that whether or not it's appropriate for an MA or even LPN is a different question than witnessing a consent form where someone didn't see or hear the conversation. Ultimately, consent is the responsibility of the provider, but the RN caring for the patient for the procedure should be asking questions for confirmation.

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Why you need a witness at all fascinates me. I've had numerous procedures and surgeries in my life, not once has a nurse or MA physically witnessed my consent. Not once.

My patient got a procedure done at bedside today. The physician simply obtained consent. My signature was not needed. I made sure consent was obtained by me giving him a consent form and then reviewing the form for signatures before the procedure. I don't need to babysit a physician getting consent. That's his job. My job is to remind him to get it.

I know all facilities are different, it seems maybe outdated or an old nurses tale that you need to physically be in the room.

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I'll tell a little bit about my clinic. So we are a specialty surgery center connected to a hospital. We actually mainly provide colonoscopy consults and colonoscopies. Before anyone asks, the risks and benefits of colonoscopy are explained to the patient during the consult and the actual consent is signed just before the procedure itself which can be as much as 3 months after the consult.

There are no RNs in the actual clinic. We have an endoscopy suite attached but those RNs do not oversee myself or the MAs. We are in charge of rooming patients for the providers (taking vitals and reviewing allergies/medications/family history, ect).

I have been told many times by first the MAs and then my second LPN that writing "to sig only" on the consent literally means I am attesting to the fact that the patient signed the form but it does NOT mean I am attesting to the fact that the patient understands anything. Apparently they figured out this system with our hospital legal person. I just feel odd signing a consent as a witness when I either was not physically present to see the signatures OR unable to follow up with the patient.

Maybe I'm looking too much into this but I think there's a misunderstanding happening between the MAs and LPNs at my clinic regarding consents and I am trying to put my finger on it.

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