Table 4 Mandatory notifications about healthcare decisions in lack of competence and/or without a valid informed consent
Legally required notifications in the medical records (Patients’ Rights Act. art. 4–3, 4–6, chapter 4A, and Health Personnel Act article 7) | NUMBER OF CHARTS (and a short description of relevant notifications found) | |
|---|---|---|
1. | Reference to that the decisional competence had been assessed? | NONE |
2. | Reference to the lack of ability to provide consent, such as “lack of competence”, “does not understand what the consent entails” or similar wording? | ONE CHART stated “lack competence” but no further notifications or information hereto was included |
3. | Noted that the conclusion on lack of decisional competence had been presented to the patient? | NONE |
4. | Noted that the conclusion on lack of decisional competence had been presented to the relatives or such other person representing the patient? | NONE |
5. | Documentation of information on patient’s preferences with regards to treatment obtained from relatives or another person representing the patient? | NONE |
6. | Noted information that the physicians admitting, treating and/or the surgeon operating the patient had conferred with a colleague or other competent health care professionals on the assessment of decisional competence and the reasons for the decision that was made? | NONE |
7. | Healthcare provided due to a vital emergency (The Norwegian Health Personnel Act art. 7). | One chart stated “vital indication” |
8. | Healthcare provided with the use of coercion (decision provided according to the Patients´ Rights Act chapter 4A, see Table 5) | NONE |