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LP1.2 Assignment: Procedures and Work Products

Directions: This is a two part assignment. First, in Kinn’s The Medical Assistant Study Guide use the Records Release Authorization
to complete Part IV: Releasing Medical Records on page 102. The
information on the form should be made up by you. This portion of the
assignment is worth 5 points.

Next, in Kinn’s The Medical Assistant textbook, read Procedure 14-2 on page 243 and then use the Informed Consent for Treatment Form to complete. This portion of the assignment is worth 5 points.

filling out the forms, it will be necessary to download and save the
documents to your computer. Make sure to include your name in the title
(for example, LP1.2 Work Product_Walters).

Submit this assignment to your instructor via the dropbox “LP1.2 Assignments: Procedures and Work Products.” This assignment is worth 10 points and will be graded according to the scoring guide below.

Scoring Guide (10 Points)

Rating Scale
5 Work meets or exceeds criterion at a high level of competence.
4 Work reflects an understanding of criterion with minor misunderstandings/misconceptions.
3 Criterion partially met, but one or more important concepts/skills are missing or flawed.
2 Work reflects an attempt to meet criterion, but significant misunderstandings/misconceptions are apparent.
1 – 0 Criterion not met or work is absent.


1. Student correctly completes and submits the Records Release Authorization form.
2. Student correctly completes and submits the Informed Consent for Treatment form.

Part V. Complete an Authorization to Release Medical Records
from using your name as the patient.



  Doctor or





________________________________________ILLNESS AND/OR





(If relative, state relationship)


I give my consent to Dr.
___________________________________ and assistants,_________________ to


  (Name of treatment/
procedure. Description in lay & medical terms)

I am aware that, during the procedure,
other procedures might be needed. I give
my consent
to do these procedures as needed.

I give my consent to receive anesthesia
and/or drugs I may need.  I know that all
procedures and anesthetics have risks like stroke, heart attack, respiratory
failure and death.  Some other risks are
tooth and nerve damage, and skin/soft tissue injury. 

I give my consent for blood and/or blood
products if I need them.  I know that all
blood and blood products can cause allergic response, fever and hives. I k now
the blood bank screens donors for infections and diseases like hepatitis and
HIV/AIDS, but I am aware there is a risk of infection.


Patient Initials


want blood or blood products, I will put my initials in this box 

and fill out
the “Statement of Refusal for Blood/ Blood Components”

I give my consent for the ­­­­­­­­­­­­­­­­­­____________  facility to use or to dispose of any
substance removed as part of my treatment or procedure. The substance might be
body fluids, tissues and organs.  I am
aware that the substance might be looked at or used in education for other
health care providers.  This material
will be disposed of using routine methods.


Patient Initials


want to be told of the risks listed below, I will put my initials in this box.

I know that each person reacts in
a different way to treatments and procedures. Therefore, the results cannot be
certain.  My questions have been answered
about the procedure.  I have been told:

  1.  The
treatment or procedure that my doctors plan to do

  2.  What
to expect from the treatment or procedure (the benefits).

  3.  The
serious risks of this treatment or procedure. 
Some of these risks can happen despite all steps   being taken to prevent them

  4.  Other
types of treatment that could be used. 
This includes no treatment.

  5.  Whether or not the treatment or
procedure is uncommon.

Some of the
known serious possible risks for the

loss of blood, infection, stroke or heart attack that can lead to death or
permanent or partial disability,

known serious possible risks are: 

Patient Initials


know I can change my mind about the consent at any time before treatment.

know that I must tell the health care staff caring for me if I change my

[img src=”file:///C:UsersWarnetteAppDataLocalPackagesoice_15_974fa576_32c1d314_3362ACTempmsohtmlclip11clip_image001.png” height=”149″ width=”722″>

Care Provider obtaining consent (PRINT NAME & INITIAL)    SIGNATURE
of person giving consent
(legally authorized to do so)

[img src=”file:///C:UsersWarnetteAppDataLocalPackagesoice_15_974fa576_32c1d314_3362ACTempmsohtmlclip11clip_image002.png” height=”30″ width=”722″>

SIGNED   TIME  AM/PM  Relationship
to patient (if applicable)

[img src=”file:///C:UsersWarnetteAppDataLocalPackagesoice_15_974fa576_32c1d314_3362ACTempmsohtmlclip11clip_image003.png” height=”2″ width=”722″>

of interpreter:  Second
witness for telephone consent:

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