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Archive for the ‘Consent’ Category

Medical Board Update: Pre-procedure consent, HIV testing

To: All Medical Staff, Housestaff, and Credentialed Providers

From: David Reich, MD
President, Medical Board
The Mount Sinai Hospital
1. HIV Testing Policy: As required by NY State, all patients 13-64 years of age and those at risk must be offered HIV testing at hospital admission, or in primary care outpatient/office and Emergency Department settings. Nursing has incorporated the assessment in workflows, but a physician or a credentialed provider (NP/PA) must counsel and consent the patient prior to testing. The seven counseling elements are as follows (abridged version):
i. HIV is the virus that causes AIDS and can be transmitted through unprotected sex, contact with blood, sharing needles, and by HIV-infected pregnant women to their infants during pregnancy/delivery/breast feeding.
ii. There are treatments for HIV/AIDS that can help an individual stay healthy.
iii. Individuals with HIV/AIDS can adopt safe practices to protect uninfected and infected people in their lives.
iv. Testing is voluntary and can be done anonymously at a public testing center (outside of Mount Sinai).
v. The law protects the confidentiality of HIV test results and other related information.
vi. The law prohibits discrimination based on an individual’s HIV status.
vii. Consent for HIV related testing remains in effect until it is withdrawn verbally or in writing.

The full policy and the DOH consent form are attached to this announcement. The DOH consent form may also be downloaded at:, and may be used until a Mount Sinai form is created.

2. Preoperative Testing Form: The new standardized form for ordering preoperative and pre-procedure testing is attached to this announcement. Requirements for laboratory testing, ECG, and chest X-ray are markedly reduced, and the pre-admission testing staff have been instructed to question any non-standard testing. Adhering to the guidelines in this template will help to minimize delays/postponement of surgery/procedures due to abnormal results and reduce costs. All perioperative nurses and anesthesiologists will consider the testing specified in the policy as sufficient to proceed with surgery.

3. Consent to Surgery/Procedure/Treatment and Anesthesia Form: The existing surgical/procedural consent form has been amended to expand “tissues” to “tissues, organs, and body fluids” so as to be more understandable for patients.

4. Prescription Pad Security: Prescription pads must always be secured in Pyxis or other locations with a high level of protection against theft or unauthorized access. This must occur in all settings, include office and outpatient areas.

5. Epic Physician Documentation: The next round of training is scheduled to be completed prior to the physician documentation go-live date of June 10th. Training will be available via e-learning and classroom modules and will take approximately four hours. Interim Chief Medical Information Officer Dr. Darrow is investigating opportunities for department-specific training.

6. Medical Student Documentation in the Medical Record: The Bylaws and the Hospital Staff Rules and Regulations will be amended to indicate that all medical student notes must be reviewed and signed by a member of the housestaff or an attending physician. Attending physicians may utilize any portion of a medical student note as part of their documentation, but may not make linking statements to notes written by medical students.

doh consent-2556
HIV Testing and Counseling Policy (A4-120)
Preop Testing Form MR1829

Written by reuben

March 5th, 2012 at 4:34 pm