Revised Consent for Operation or Procedure forms

Effective Tuesday, Aug. 13, 2019, Consent for Operation or Procedure forms will be updated to ensure compliance with all regulatory bodies, including the Iowa Administrative Code, and to provide greater clarity and consistency to patients and providers. Revisions include:

  • New required field: Name of provider(s) obtaining consent/having consent discussion
  • New required field: Risks
  • New field: “Not Applicable” box for blood transfusion
  • New section: Scribe and/or interpreter, if applicable
  • New statement before signature: Patient allowed to ask questions
  • New requirement: Printed name and relationship of patient/person signing consent
  • New signature option: Witness to patient signature, may be non-LIP
  • Clarification: Name of provider(s) authorized to perform the procedure cannot include “and associates/staff/team.” The names of the actual or potential provider(s) performing the procedure must be listed.

To view the changes, which include new required information and new fields, a draft of the form can be viewed here.

A new “Series” Consent for Operation or Procedure form will also be rolled out on Aug. 13, which is intended for identical procedures and valid for a maximum of two years. It allows the patient to only sign one time for multiple identical procedures.

Additionally, an e-signature pilot of the Consent for Operation or Procedure form will also begin on Aug. 13 in the Urology Clinic and some transplant areas.

What do I need to do?

Work areas are responsible for discarding all versions of the old forms and replacing with the new forms on Aug. 13. Revised forms will have a revision date of 8-2019 in the bottom left corner. Forms stocked in hospital stores (#947882 and #922373), and on the medical record forms website will be updated and available on Aug. 13.

Forms that have already been signed for future procedures will be honored until Dec. 1, 2019.

To assure that current, approved versions of this important document are always in use, please do not create or retain electronic versions apart from those posted on the website unless approved by the Health Information Management Department.

For questions about where to find the updated forms or to create a procedure-specific and/or “Series” consent, please email Erin DuFrane-Woods at or Brooke Zittergruen at

1 comment

  1. Question the “Not Applicable” box for blood transfusion. This may be appropriate for very minor procedures. Another situation might be a patient who refuses blood on religious grounds. Still another situation might be that the patient “doesn’t want to have a blood transfusion.”

    However, there are occasions when the surgeon does not expect to lose blood, but conditions change during operation and significant blood loss occurs. If blood transfusion is needed, but the “NA” box is checked, the appropriate response may not be clear. What if transfusion is denied and a complication occurs? What if blood is administered and a problem occurs?

    I think this topic is too important to be covered by a check box. If a patient refuses blood for religion reasons, and understands that death may occur without transfusion, these statement should be explicitly stated in the patient record.

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