The Patient Consent Form For Case Report is a critical document used in New Zealand healthcare settings when medical practitioners wish to publish individual patient cases in medical literature or academic journals. This document serves as a formal agreement between the healthcare provider and the patient, ensuring informed consent is obtained in compliance with the Health Information Privacy Code 2020 and the Code of Health and Disability Services Consumers' Rights 1996. The form must be completed before any patient information can be used in a published case report, and it includes specific details about what information will be published, how patient privacy will be protected, and the rights of the patient regarding their information. It represents a crucial step in contributing to medical knowledge while protecting patient privacy and maintaining ethical standards in medical research and publication.
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1. Title and Document Identification: Clear identification of the document as a Patient Consent Form for Case Report, including institution name and form version/date
2. Patient Information: Patient's name, date of birth, contact details, and medical record number (while noting that this may be anonymized in the actual case report)
3. Healthcare Provider Information: Name and contact details of the primary healthcare provider/researcher responsible for the case report
4. Purpose of the Case Report: Clear explanation of why the case report is being written and its intended use in medical literature
5. Information to be Published: Specific details about what medical information will be included in the case report
6. Confidentiality Statement: Explanation of how patient's privacy will be protected and what identifying information will be removed/modified
7. Rights Statement: Clear outline of patient's rights, including the right to withdraw consent
8. Consent Declaration: Formal statement of consent with specific permissions being granted
9. Signatures: Space for patient (or legal representative) signature, date, and witness signature if required
1. Interpreter Declaration: Required when the patient's primary language is not English or when an interpreter is used
2. Legal Representative Authorization: Required when the patient is unable to provide consent themselves
3. Photography/Images Consent: Required when the case report will include photos, x-rays, or other images of the patient
4. Future Use Permission: Optional section for consent to use the case report in future medical education or research
5. Financial Disclosure: Required when there are any financial implications or compensation related to the case report
6. Publication Details: Optional section specifying intended publication venues or specific journals
1. Description of Case Report: Detailed outline of the medical condition or procedure that will be described in the case report
2. Image Schedule: List and descriptions of any images or medical records that will be included in the publication
3. Privacy Protection Measures: Detailed description of steps taken to protect patient privacy and confidentiality
4. Patient Rights Information Sheet: Detailed information about patient rights under New Zealand law regarding medical information and privacy
5. Withdrawal Process Guide: Detailed information about how to withdraw consent and the implications of withdrawal
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