Informed Consent

Informed consent is a continuous dialogue between the chiropractor and patient and is foundational to the chiropractor-patient relationship. The performance of competent informed consent is demonstrated with the documentation of the two-part communication (both written and verbal must be recorded in the patient health record) between the chiropractor and patient, as an essential practice requirement in providing safe, competent and ethical chiropractor care.

The first part of the communication occurs when the chiropractor informs the patient’s decision(s) with necessary information regarding recommended diagnostic or therapeutic procedures. Informed consent provides the vehicle for chiropractors to discuss with their patient information about the benefits, risks and side effects of recommended procedures.

The second part of the communication exchange occurs when the patient verbally or in writing decides to consent (give permission) to the recommended procedures.

Chiropractors must obtain written informed consent when a new or changed treatment recommendation is made. Treatment recommendations occur when the patient receives a new or changed diagnosis or a new treatment recommendation is proposed.

Reference to patient throughout is understood to be inclusive of the patient or, where appropriate, the substitute decision maker.

How to practice informed consent

To enable regulated members to meet the informed consent standards, performance expectations are provided in the following sections:

Informed consent during patient engagement.
Implied consent during patient engagement.
Informed consent for treatment recommendations.

Informed consent during patient engagement

Informed consent dialogue must occur each time a chiropractor engages with a patient to deliver chiropractic services. Chiropractors must have the patient’s verbal consent prior to providing chiropractic services, including diagnostic and therapeutic procedures.

When should a chiropractor inform the patient?

Before you provide chiropractic services, always inform the patient of:

What diagnostic or therapeutic procedure you are proposing.
Why you are proposing the diagnostic or therapeutic procedure.
How you will perform the proposed diagnostic or therapeutic procedure.
Where you will contact the patient when performing the diagnostic or therapeutic procedure.
When you will contact the patient near the pelvis or breast tissue to perform a diagnostic or therapeutic procedure.
What clothing you may need to shift to perform the diagnostic or therapeutic procedure.
Their right to tell you to stop the diagnostic or therapeutic procedure at any time.

When should a chiropractor receive patient consent?

Prior to providing any procedure in delivering chiropractic services, the chiropractor must have verbal consent from the patient. When the chiropractor needs to touch near the patient’s pelvis or breast tissue, or reposition clothing, the patient must provide verbal consent for touch before the chiropractor commences care.

When should the chiropractor perform the proposed procedure?

Chiropractors should only perform the diagnostic or therapeutic procedure activity after the patient provides verbal consent.

Recording informed consent in the patient’s health record

The chiropractor must record the patient’s verbal informed consent in the patient health record. Without a note of the patient’s consent in the patient health record, there is no evidence of informed consent.

Patient health records must be dated, accurate, legible and comprehensive. All services provided by the chiropractor must be documented by the chiropractor. A comprehensive record includes a record of the patient’s verbal consent for the proposed diagnostic or therapeutic procedures.

The following examples represent a comprehensive record of informed consent:

Patient consent for proposed assessment and treatment of the spine.
Patient consent to gown and have gown opened in back to examine the full spine.
Patient consent to contact over the hip flexors, glutes and piriformis.
Patient consent to skin contact under clothing for treatment of levator scapulae.
Patient consent for auscultation of heart and lungs on skin, with shirt lifted.

Implied consent during patient engagement

The contrast to informed consent is implied consent. Implied consent is the notion that a patient has consented to a health care procedure without their consent expressly stated. Implied consent includes the notion that a patient consents to physical touch without their verbal consent.

There is no substitute for informed consent and chiropractors must not rely on implied consent in delivering chiropractic services.

Implied consent results from the chiropractor’s failure to receive the patient’s consent before performing a diagnostic or therapeutic procedure. Examples of implied consent (that is not getting express consent from the patient before the procedure), include:

Moving patient clothing.
- i.e., Shifting the patient’s pants or undergarments when examining or treating in the pelvic region, such as contacting the hip flexors, adductors, quads, glutes, or any area close to the patient’s genitals, without the patient’s verbal consent.
- i.e., Shifting the shirt, undershirt, undergarments, or bra when examining or treating the shoulder girdle, pectoralis muscles or thorax around breast tissue.
>Touching the patient, including areas that are personally sensitive to the patient.
Failing to inform the patient of where they will be touched and why the touch is necessary to providing care.
- i.e., Entering a room with the patient lying on their stomach and making patient contact.
- i.e., Performing a test on the patient when they do not know what the test is for.
- i.e., Trying a treatment on a patient that they have not discussed.
Telling the patient you are going to touch them instead of asking if it is okay to touch them and receiving consent.

Recording implied consent in the patient health record

A comprehensive patient health record of the services provided by the chiropractor would include when the patient provides informed consent (written and verbal) and when chiropractor demonstrates implied consent.

If a chiropractor performs implied consent, the following statements are examples of notes that could appear in the patient health record:

Examined/treated hip flexors without patient consent.
Examined/treated hip flexors without patient consent, stopped treatment to obtain consent, then returned to exam/treatment.
Examined/treated without patient consent. Noticed patient hesitant during treatment and patient asked why contact was made with hip flexors. Provided patient information post treatment.

Informed consent for treatment recommendations

Chiropractors must obtain written informed consent when a new or changed treatment recommendation is made.

Patients may raise new health complaints after the initial visit and during ongoing patient engagement.

The chiropractor must consider the patient complaint, complete a history and examination and provide a diagnosis before making a treatment recommendation.

As part of the informed consent dialogue, chiropractors are responsible for disclosing:

Diagnosis and treatment recommendation(s).
Treatment recommendation(s) include:
1. Benefits,
2. Prognosis,
3. significant risks associated with treatment,
4. the risks of no treatment,
5. reasonable alternatives and
6. associated costs.
Provide the patient an opportunity to ask questions about the treatment recommendation(s).
Respond to patient questions to their satisfaction.
The requirement for the patient to sign the informed consent document prior to treatment.

Requirement for written informed consent in the patient record

After the treatment recommendation dialogue between the chiropractor and patient, written consent is completed when the required document is:

signed by the patient.
signed by the chiropractor.
dated by both patient and chiropractor.

The document:

indicates the patient’s consent to treatment.
indicates the doctor’s obligation to keep patients informed by advising them of any changes to the treatment or the risk of treatment.
must be present in the patient health record.

Advice to the profession

Informed consent is a progressing concept in practice and is adapting to support patients. How a chiropractor practiced informed consent ten years ago looks different than how informed consent is practiced today. However, the principles of competent informed consent are consistent. It is reasonable that chiropractors maintain and enhance their competence and may need to acquire new knowledge or skills and change attitudes to perform informed consent to the expectations of patients.

Informed consent competencies

Competence means the combined knowledge, skills, attitudes and judgment required to provide professional services.

The Federation of Canadian Chiropractic published the entry to practice competencies for chiropractors, which establish the key expected abilities for chiropractors. The competencies are based on roles that a chiropractor assumes in practice. The roles include neuromusculoskeletal (NMS) expert, communicator, collaborator, health advocate, scholar, professional and leader.

A chiropractor’s competencies in informed consent include:

Identify indications, contraindications, and risk factors for diagnostic and therapeutic procedures, explain the anticipated benefits, potential complications and effects to patients. (NMS expert)
Recognize when values, biases, or perspectives of patients, chiropractors or other health care professionals may have an impact on quality of care and modify the approach to the patient accordingly. (communicator)
Provide a clear and accurate explanation about the plan of care, recommendations, and prognosis for the goals of proposed interventions, as well as the risks and benefits of proposed interventions within a structured report of findings. (communicator)
Utilize communication skills and strategies that help your patient to practically apply evidence-based health information. (communicator)
Participate in a continuing dialogue with the patient while maintaining informed consent as part of the evolving process of patient engagement. (communicator)
Document relevant information and perspective of patients and families and/or caregivers and/or support persons, colleagues, and other health professionals. (communicator)
Document clinical information and encounters in an accurate, readable, complete, timely and accessible manner in compliance with regulatory and legal requirements. (communicator)

The role of communicator is of ultimate importance in performing competent informed consent in practice. Regardless of your current communicator competence there is always an opportunity to professionally develop knowledge, skills, attitudes and decision making to enhance performance.

Professional development and informed consent

Health care professionals should consider and adapt practice based on their performance. Work with colleagues and peers to understand your strengths and growth opportunities as a communicator. When there are performance gaps close them by seeking new or updated knowledge, practicing the necessary skills and abilities, focusing on patient safety and experience.

Chiropractors should self-identify performance gaps and seek and complete professional development to maintain and improve competence. The chiropractor should, as necessary, change practice performance patterns to demonstrate competent practice when addressing performance gaps.

Public harm and informed consent

Informed consent is essential to patient and public safety. The CCOA is mandated to establish standards of practice and code of ethics that support regulated members in providing safe, competent and ethical chiropractic care.

Concerns, complaints, and claims

When practitioners fail to perform safe, competent and/or ethical care, their risk of a professional concern or complaint, or negligence claim increase. Competent informed consent and its documentation is essential to patient safety.

When a standard is not met, the patient may experience harm. The patient or the Complaints Director has the right to file a complaint when a regulated member does not meet a standard.

The best way for a regulated member to avoid the stress and challenges associated with concerns, complaints and negligence claims is to meet informed consent standards.

Resources and Documents

See other patient forms.