Documentation
Documentation of ethics consultations is dependent on the level of consultation performed.
A Level I consultation requires no documentation in the patient's medical record, but does require submission of a Consultation Report Form.
A Level II consultation requires immediate hand-written documentation in the patient's medical record that summarizes the consultation findings, analysis, and recommendations reached that summarizes the consultation findings, analysis, and recommendations reached by the Consultant. There may be a rare circumstance in which documentation of a Level II consultation in the patient's medical record is not appropriate. These situations should be discussed with the ECS Chair or Vice-Chair. The Ethics Consultant will use professional discretion in these circumstances. All Level II consultations require submission of a Consultation Report Form to the ECS Chair.
A Level III consultation requires an immediate written documentation in the patient's medical record that outlines a comprehensive summary of the consultation and the recommendations that were developed following the panel session. All Level III consultations require submission of a Consultation Report Form to the ECS Chair.
Ethics consultation information accompanies a patient upon transfer to another facility after notification of the attending physician. The transferring Ethics Consultant should verbally notify the ethics resource person at the accepting institution. Written consultation information is sent to the facility as part of the patient medical record and to the ethics resource person at the accepting facility, as indicated or desired.