Sign A Consent Without Witnessing Actual Signature

[knotizer12]

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?

[MunoRN, RN]

The typical interpretation of "witness" is that they have confirmed that the patient signed the consent, this doesn't require witnessing the actual signature, it only requires saying something to the effect of "is this your signature" or "did you sign this". Nurses are often held to a different standard for confirming consent than non-licensed individuals, such as MAs, in that they are expected to confirm that the patient consents to the procedure (that they understand the purpose of the procedure, the risks, etc).

[FurBabyMom, MSN, RN]

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I know all facilities are different, it seems maybe outdated or an old nurses tale that you need to physically be in the room.

I think a lot of it depends on the procedure itself. When I worked the floor and a surgeon did a first dressing change, pulled a drain, removed sutures, none of those required a super intensive consent process.

It makes sense that for more invasive procedures a higher level of detail or scrutiny is provided. There is an additional form required for sterilization procedures if the procedure is not life threateningly emergent (ectopic that has hemorrhaged and the patient already only has one tube/ovary, postpartum or post procedure bring back for hemorrhage, etc.). Additional paperwork is required for sterilizations whether male or female (BSOs, TAH/BSOs,, and/or vasectomies).

I'm happy to discuss what I know and what is practiced, but I think some of the folks who are having issues with discerning what the most correct answer is in their practice/facility/state, might want to consult legal/risk management or ask their manager to feature this topic as a continuing education topic. I can't give particulars outside of my own facility, though I am familiar with my state's practice act and regulations).

[knotizer12]

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.

I guess it's facility vs facility. Actually this is a very good question. Why do we need witnesses at my facility? I can ask around.

[MunoRN, RN]

I guess it's facility vs facility. Actually this is a very good question. Why do we need witnesses at my facility? I can ask around.

I think people incorrectly assume that a signed consent for certain procedures is a legal requirement, and that there are legally defined requirements for a written consent, which there are not. It's up to each facility to determine what they want to have signed consents for rather than just verbal consents, the level of documentation, including witnesses, is also up to each provider/facility to determine.

[Rose_Queen, BSN, MSN, RN]

I guess it's facility vs facility. Actually this is a very good question. Why do we need witnesses at my facility? I can ask around.

AN now has an ask a nurse attorney feature. Perhaps you could try it out there as well.

[cleback]

I find it interesting that a common interpretation of obtaining consent is that we're to ensure that risks and benefits were explained and that the patient understands them when the conversation of risks and benefits of a procedure is really not within the scope of rn practice (otherwise, if we had that knowledge and training, we could theoretically develop the medical care plan). Personally, I find this to be a case of "what's always been done" vs what actually is a meaningful practice.

[knotizer12]

I think one of the reasons this issue is so "near and dear" to me is because, for the most part, the clinics do not hire many nurses. At wound care and primary care, you have a handful of RNs to do the actual wound care and phone triage but at my clinic there are only two LPNs.

When I was hired, I was pretty much an MA in what I was expected to do; which is fair to an extend because they really needed someone to room for our PA. Maybe I'm being prideful, but I'm not an MA. I'm an LPN, albeit a new one. The clinic is finally to the point in staffing where I am actually start doing more "nurse" duties instead of MA duties.

To me, signing your name under the "witness" line and writing "to sig only" is something an MA would do whereas a nurse would follow up to make sure the patient actually understood what they were signing and did not have any additional questions.

Maybe I'm too prideful.

[knotizer12]

I find it interesting that a common interpretation of obtaining consent is that we're to ensure that risks and benefits were explained and that the patient understands them when the conversation of risks and benefits of a procedure is really not within the scope of rn practice .

I agree. I just mean in terms of asking "do you have any other questions?" and being able to tell the doctor to go back and speak to them or give them a call later. Not just sign as a witness and forget about it.

[FolksBtrippin, BSN, RN]

I find it interesting that a common interpretation of obtaining consent is that we're to ensure that risks and benefits were explained and that the patient understands them when the conversation of risks and benefits of a procedure is really not within the scope of rn practice (otherwise, if we had that knowledge and training, we could theoretically develop the medical care plan). Personally, I find this to be a case of "what's always been done" vs what actually is a meaningful practice.

Doing a risk / benefit analysis of the procedure is outside of our scope. Assessing whether the patient has given informed consent is in our scope. The "informed" part of the consent is the part where the patient understands the risk/benefit analysis that has been explained to them.

Some reasons why an RN might determine that consent was not obtained due to patient knowledge deficit:

1. Pt has a language barrier and did not have an interpreter.

2. Pt has a legal guardian.

3. Pt was under the influence of a drug (prescribed or not) that prevented comprehension.

Those are just a few reasons. You need to use your judgment.

If the nurse assesses that the patient does not understand the risk/benefit analysis that the surgeon has presented, the nurse does not go ahead and explain the risk/benefit analysis. That would be going outside nurse's scope. The nurse gets the surgeon and tells him/her why we don't have consent and then the surgeon takes it from there.

[FolksBtrippin, BSN, RN]

I think one of the reasons this issue is so "near and dear" to me is because, for the most part, the clinics do not hire many nurses. At wound care and primary care, you have a handful of RNs to do the actual wound care and phone triage but at my clinic there are only two LPNs.

When I was hired, I was pretty much an MA in what I was expected to do; which is fair to an extend because they really needed someone to room for our PA. Maybe I'm being prideful, but I'm not an MA. I'm an LPN, albeit a new one. The clinic is finally to the point in staffing where I am actually start doing more "nurse" duties instead of MA duties.

To me, signing your name under the "witness" line and writing "to sig only" is something an MA would do whereas a nurse would follow up to make sure the patient actually understood what they were signing and did not have any additional questions.

Maybe I'm too prideful.

You are not being prideful. You are correct. The MA cannot assess patient knowledge. You can and ought to.

[ArrowRN, BSN, RN]

A witness does not verify the information provided to the patient, the purpose of a witness is that the provider spoke to the correct person and and that person signed the form and agrees to the procedure. In medical field its based on facility policy but only RN's can witness at our facility. Ideally yes the witness should be there in the room but realistically anyone can sign as witness.

When you go to a notary, a total stranger, for them to witness, they dont know you, nor will they often not know the information stated in the document you need notarized, they look at your ID, see you sign the paper and witness that yes they see you signed it and you affirm you are that same person.

[JKL33]

I find it interesting that a common interpretation of obtaining consent is that we're to ensure that risks and benefits were explained and that the patient understands them when the conversation of risks and benefits of a procedure is really not within the scope of rn practice (otherwise, if we had that knowledge and training, we could theoretically develop the medical care plan). Personally, I find this to be a case of "what's always been done" vs what actually is a meaningful practice.

The problem is that as soon as your signature is anywhere on the paper in association with anything other than witnessing signature only, there is the possibility that you will be called upon to answer for x, y, z that goes beyond signature.

For example, your take is that you are pretty much witnessing signature only. Your form may or may not spell that out very clearly, depending upon how your employer's legal department has written it.

So, do you think you might be questioned at a later time if you had sauntered into a room of a patient totally snowed with medications and had them sign a consent form and then later they say they didn't sign it? What would you be questioned about?

One way or another there is at least some element of "consent itself being given reasonably" that you (RN) are attesting to. Otherwise, why can't the unit clerk have it signed? Why can't the physician have it signed. Why can't the patient's family member witness their signature?

If you think this through, you will see that, by the sheer implications that arise when involving an RN, you are being asked to attest to a little bit more than the fact that the correct patient signed a form....KWIM?