From: Clinical ethics consultation documentation in the era of open notes
Clinical Ethics Consultation Documentation Elements |
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1) Gather Data Relevant Clinical Facts -Demographic -Medical -Socioeconomic -Psychosocial Stakeholder Values -Religion -Beliefs -Preferences Relevant Local/Institutional Policies -Institutional -Legal |
2) Assess Whether the Problem is Ethical in Nature |
3) Identify Relevant Ethical Principles, Duties, and/or Concepts -Autonomy, beneficence, non-maleficence, and justice -Veracity -Duty to provide care -Fidelity -Confidentiality -Professional ethics |
4)Determine Whether Additional Data and/or More Discussions are Necessary |
5) Provide an Overall Ethical Assessment -Brief summary of clinical situation -Identification of related ethical issues |
6) Present Ethical Plan of Action Supported by and Balancing of: -Principles -Rights -Consequences -Casuistry -Professional standard of practice -Conscientious practice -Institutional and legal policies |
7) Evaluate and Confirm Coherence of Conclusion |
8) Provide Ethics Recommendation(s) |