Informed Consent Procedures Template for Australian General Practices

What's in this template?

This informed consent procedures document covers all aspects of consent in a general practice setting. It maps to RACGP Criterion C1.3 — Informed patient decisions and covers 17 sections:

1. Purpose — ensuring consistent, respectful, and legally sound consent processes
2. Scope — all consultations, examinations, treatments, procedures, and information sharing
3. Principles of Informed Consent — the three elements: voluntary, informed, capacity
4. When Consent Is Required — implied consent (routine consultations), explicit verbal consent (examinations, minor procedures, telehealth), written consent (significant procedures, research)
5. The Consent Discussion — plain language, teach-back method, material risks (Rogers v Whitaker), patient-specific risks, written information supplements
6. Documenting Consent — what to record, documentation examples, refusal documentation
7. Capacity to Consent — four-part capacity test, decision-specific capacity, fluctuating capacity, formal assessment, second opinions
8. Children and Young People — parental consent, Gillick competence/mature minor doctrine, age-appropriate involvement, confidentiality considerations
9. Refusal of Treatment — patient's right to refuse, documentation of refusal and risk discussion, continued care obligation
10. Consent for Telehealth — modality consent, limitations discussion, identity/location confirmation
11. Consent for Information Sharing — third-party disclosure (insurers, employers, family), research consent, exceptions (mandatory reporting)
12. Advance Care Directives — ACD support, filing and flagging in records, state-specific legislation
13. Interpreter Services — professional interpreter requirement, TIS National (131 450), documentation
14. Emergency Situations — treatment without consent when delay would cause serious harm
15. Training — induction, annual refresher, registrar-specific training
16. Related Policies — Chaperone, Privacy, Handover, Health Records, Clinical Risk
17. Review History

Editable placeholder fields

• {{practice_name}}, {{abn}}, {{practice_address}}, {{phone}}, {{email}}
• {{practice_principal_name}}, {{review_date}}, {{next_review_date}}

How to customise this template

1. Download and fill in all {{placeholder}} fields
2. Identify your state/territory's substitute decision-maker legislation — update the note in Section 7 with the relevant Act
3. Decide your written consent thresholds — which procedures at your practice require written vs verbal consent
4. Create or source consent forms for procedures that require written consent (excisions, IUD, implanon, etc.)
5. Brief all clinical staff on the three elements of valid consent and documentation requirements
6. Update your PMS templates to include consent documentation prompts for procedures

Frequently asked questions

What is a "material risk" under Rogers v Whitaker?

A material risk is one that a reasonable person in the patient's position would consider significant in deciding whether to proceed with a treatment or procedure. It also includes risks that the practitioner knows or should know are significant to this particular patient. You don't need to disclose every possible risk — focus on those that would matter to the patient's decision.

When can a minor consent for themselves?

Under the Gillick competence doctrine, a person under 18 can consent to their own treatment if they have sufficient maturity and understanding to fully comprehend the proposed treatment. This is assessed case-by-case by the treating practitioner. It commonly arises in sexual health, mental health, and substance use consultations.

Do we need written consent for every procedure?

No. Implied consent covers routine consultations. Verbal consent (documented in the record) is sufficient for most examinations and minor procedures. Written consent is recommended for procedures with significant risks. The template provides guidance on which level is appropriate.

Can I use this for AGPAL or QPA accreditation?

Yes. Both accrediting bodies assess against RACGP Criterion C1.3. Surveyors will check that consent processes are documented in clinical records, staff can describe how consent is obtained, and the practice has procedures for capacity assessment and refusal of treatment.