CalMHSA has worked with Manatt to determine what are the legal requirements for medication consents. These recommendations are specific to consents for medications and not general informed consent/consent to treat. The general summary is that in most situations, a separate, signed “Medication Consent” document is no longer required. Consents for medications can be captured/documented in the prescriber’s progress note. Below, you can find recommended language to use in these progress notes, based on the type of medication prescribed.
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Type of medication/setting |
Template to use |
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General Psychotropics, Including Antipsychotics |
General Psychotropics, Including Antipsychotics |
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Opioids for Pain Management (Adults and Minors) |
Opioids for Pain Management (Adults and Minors) |
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MAT in an OTP/NTP setting |
MAT (OTP/NTP) |
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MAT outside of an OTP/NTP setting |
MAT (OTP/NTP) |
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All other medications that don’t fall in the categories above |
Use medical judgement, depending on the drug and the patient |
Click HERE to view the full Memo.
General Psychotropics, Including Antipsychotics
Explained to patient that I will be prescribing the following medication(s) for treatment of their presenting symptoms:
[INSERT: Drug Name, Dose /Dose Ranges, Frequency, Route, Dispense Amount and Recommended Duration]
Additionally, we reviewed the nature of the patient’s medical condition; the reasons/goals for taking such medication(s), including the likelihood of improving or not improving without such medication(s), and that consent, once given, may be withdrawn at any time by stating such intention to any member of the treating staff; the reasonable alternative treatments available, if any; the probable side effects of these drugs known to commonly occur, any particular side effects likely to occur with the particular patient, and the possible additional side effects which may occur to patients taking such medication beyond three months. The patient was advised that such side effects include:
[INSERT RELEVANT SIDE EFFECTS DISCUSSED]
[Patient or guardian/parent] verbally indicated understanding the nature and effect of the medications noted above and consents to administration of the medication(s) noted above.
Additional Comments (if applicable):
Opioids for Pain Management (Adults and Minors)
Explained to patient [and if a minor, the guardian/parent] that I will be prescribing the following medication(s) for treatment of their presenting symptoms:
[INSERT: Drug Name, Dose /Dose Ranges, Frequency, Route, Dispense Amount and Recommended Duration]
Additionally, we reviewed the nature of the patient’s medical condition; the reasons/goals for taking such medication(s), including the likelihood of improving or not improving without such medication(s), and that consent, once given, may be withdrawn at any time by stating such intention to any member of the treating staff; the reasonable alternative treatments available, if any; the probable side effects of these drugs known to commonly occur, any particular side effects likely to occur with the particular patient, and the possible additional side effects which may occur to patients taking such medication beyond three months. The patient was advised that such side effects include:
[INSERT RELEVANT SIDE EFFECTS DISCUSSED]
The following risk and benefits were discussed:
- The risks of addiction and overdose associated with the use of opioids and education regarding overdose prevention;
- The increased risk of addiction to an opioid if the patient is suffering from both mental and substance abuse disorders; and
- The increased risk of taking an opioid with a benzodiazepine, alcohol, or another central nervous system depressant.
Patient [and if a minor, the guardian/parent] verbally indicated understanding the nature and effect of the medications noted above and consents to the administration of the medication(s) noted above.
Additional Comments (if applicable):
MAT (OTP/NTP)
Explained to patient [and if a minor, the guardian/parent] that I will be prescribing the following medication(s) for treatment of their presenting symptoms:
[INSERT: Drug Name, Dose /Dose Ranges, Frequency, Route, Dispense Amount and Recommended Duration]
Additionally, we reviewed the nature of the patient’s medical condition; the reasons/goals for taking such medication(s), including the likelihood of improving or not improving without such medication(s), and that consent, once given, may be withdrawn at any time by stating such intention to any member of the treating staff; the reasonable alternative treatments available, if any; the probable side effects of these drugs known to commonly occur, any particular side effects likely to occur with the particular patient, and the possible additional side effects which may occur to patients taking such medication beyond three months. The patient was advised that such side effects include:
[INSERT RELEVANT SIDE EFFECTS DISCUSSED]
The following risk and benefits were discussed:
- The risks of addiction and overdose associated with the use of opioids and education regarding overdose prevention;
- The increased risk of addiction to an opioid if the patient is suffering from both mental and substance abuse disorders; and
- The increased risk of taking an opioid with a benzodiazepine, alcohol, or another central nervous system depressant.
Patient verbally indicated understanding the nature and effect of the medications noted above and consents to the administration of the medication(s) noted above.
Additional Comments (if applicable):