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Patient Rights & Informed Consent Audit

Cette liste de contrôle est en anglais.

Audit of patient and resident rights covering notification of rights, informed consent, advance directives, grievances, and privacy across acute and long-term care.

CMS 42 CFR 482.13TJC Rights & Responsibilities (RI)CMS 42 CFR 483.10

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Notification of Rights

  • Is each patient/resident informed of their rights before or at the start of care? *
  • Are rights information and consent materials provided in a language/manner the patient understands? *
  • Is the patient informed of the identity/role of physicians and practitioners responsible for their care? *

Informed Consent & Decision-Making

  • Is informed consent obtained and documented for procedures/treatments requiring it? *
  • Does the consent form include risks, benefits, alternatives, and the practitioner performing the procedure? *
  • Is the patient's right to refuse care/treatment honored and documented? *
  • Are surrogate decision-makers identified and documented when the patient lacks capacity? *

Advance Directives

  • Is the patient asked whether they have an advance directive, and is it documented in the record? *
  • Is written information about advance directive rights provided at admission? *

Grievances & Complaints

  • Is there a documented process to promptly resolve patient grievances? *
  • Does the patient receive written notice of the grievance decision with steps, results, and completion date? *
  • Are patients informed of the right to file a complaint with the state agency regardless of internal process? *

Privacy, Confidentiality & Freedom from Abuse

  • Is personal privacy provided during examinations, treatments, and personal care? *
  • Is the patient free from all forms of abuse, neglect, and harassment? *
  • Are visitation rights honored without discrimination, with any clinical restrictions documented? *

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