Nursing Homes: Informed Consent Form Instructions
These informed consent forms are for use in Wisconsin nursing homes that prescribe psychotropic medications to residents. To find out more, see Informed Consent for Psychotropic Medications for Nursing Home Residents.
The forms can be used for a wide range of facilities. The forms have been updated to include information required by Wis. Stats. 50.08.
These forms are reviewed at least every two years. They also are routinely updated for new medications and important changes in medication labeling, as well as new uses and warnings approved by the U.S. Food and Drug Administration. Online versions have the most recent revision date at the top.
It is the nursing home's responsibility to provide residents with the most current information. Make sure you use the most updated form. If a form isn't available or seems out of date, email Doug Englebert at douglas.englebert@dhs.wisconsin.gov.
Using the forms
Find the form you need at Informed Consent for Medications F-24277 Series. If a form for a specific drug isn't listed, use a blank form. The forms can be printed on demand. Get the medication information from the package insert, Physician's Desk Reference, U.S. Food and Drug Administration, or other source.
Fill out the form using this guide:
Introduction: Identify the resident in this section.
Section 1: State the reason for the medication and its expected benefits.
Section 2: (Alternatives): Check this section to see if other interventions are suggested. Some of the alternatives listed won't apply to most nursing home residents. Remember, this form is used in many different settings.
Section 3: (Consequences): Identify what could happen if a medication is not used. Many of the consequences listed won't apply to nursing home residents.
Section 4: Be aware of side effects and risks of the medication.
Signature and rights: The resident, guardian, or Power of Attorney for Health Care must read, understand, and sign in this section. Each page has a line for the person to sign or initial. This is to confirm that the resident, guardian, or Power of Attorney for Health Care received each page.