Physiotherapy patient consent procedure

Purpose

To make sure every patient gives informed consent before being assessed or treated, that consent is recorded, and that patients know they can change their mind at any time.

Scope

Every assessment and treatment by practitioners at the clinic, including manual therapy, exercise, electrotherapy, dry needling and acupuncture, and treatments that need the patient to undress or be touched in sensitive areas. It applies to every practitioner and student.

Responsibilities

Definitions

Informed consent

Agreement given freely by a patient who understands what is proposed, its risks and benefits, and the other options.

Capacity

The patient’s ability to understand the information, weigh it up and make a decision.

Chaperone

A person who is present during an examination or treatment, at the patient’s or practitioner’s request.

Written consent

A signed form recording the patient’s agreement, used alongside the discussion, not instead of it.

What you need

• The clinic’s consent and privacy information for patients
• Written consent forms for higher-risk treatments, such as dry needling
• The patient’s clinical record
• Contact details for interpreter services

Procedure

1. Introduce yourself and the session

   Tell the patient your name and role, and explain what the first session will involve.

2. Explain the assessment

   Before you start, explain what you’ll look at and do, including any need to undress or touch, and offer a gown and a chaperone.

   • Say which parts of the body you’ll look at and touch, and why
   • Offer a gown, a towel or a chaperone before the patient undresses

3. Explain the treatment plan

   Explain the treatment you recommend, why, the expected benefits, the common and serious risks, the other options including no treatment, and roughly how many sessions.

   • What you’ll do, and roughly how many sessions
   • The expected benefits
   • Common risks, such as soreness after treatment
   • Rare but serious risks of the treatment
   • Other options, including no treatment
   • Costs, if they haven’t been discussed

4. Check they understand

   Ask the patient to tell you in their own words what you’ll do, and answer their questions. Use an interpreter where needed, not a family member if you can avoid it.

5. Check capacity

   If you doubt the patient can understand and decide, don’t treat. Follow your local rules for patients who lack capacity, involving their legal decision-maker.

   Caution: For children and young people, follow your local rules on who can consent, which may be the parent or guardian or the young person themselves.

6. Get consent and record it

   Ask the patient whether they agree. Record what you explained, the risks discussed, their questions and their decision in the clinical record.

   • What was explained
   • The risks discussed
   • The patient’s questions and your answers
   • The patient’s decision, and the date

7. Get written consent for higher-risk treatments

   For dry needling, acupuncture, spinal manipulation or any treatment your clinic lists, have the patient sign the written consent form after the discussion.

8. Check consent again when things change

   Check consent again before a new treatment or technique, and whenever the patient seems unsure or uncomfortable.

9. Respect withdrawal

   Stop straight away if the patient withdraws consent at any time, and record it.

   Caution: Never continue a treatment or examination after a patient asks you to stop, even if it’s nearly finished.

Records

• Consent discussions and decisions in each patient’s clinical record, kept for as long as your health records rules require.
• Signed written consent forms for higher-risk treatments.
• Records of chaperones offered and present.
• Staff training records and consent audit results.

Related documents

• Privacy and clinical records policy
• Chaperone policy
• Dry needling procedure
• Complaint handling procedure

Revision history