Attachment L - Draft CV Checklist

Attachment L

Draft CV Checklist 

I have discussed the following with the patient:

	Item
☐	The possible or likely nature of the illness or disease;
☐	The degree of uncertainty of any diagnosis arrived at
☐	Other options for investigation, diagnosis and treatment
☐	The proposed approach to investigation, diagnosis and treatment What the proposed approach entails The expected benefits Common side effects Material risks of any intervention Whether the intervention is conventional or experimental Who will undertake the intervention
☐	Other options for investigation, diagnosis and treatment
☐	The degree of uncertainty about the therapeutic outcome
☐	The likely consequences of choosing or not choosing the proposed diagnostic procedure or treatment, or of not having any procedure or treatment at all
☐	Any significant long term physical, emotional, mental, social, sexual, or other outcome which may be associated with a proposed intervention
☐	The time involved in treatment and recovery
☐	Explained how treatment choice could affect a patient's finances. Total costs of care Out of pocket costs. Costs of all medications Medication costs unlikely to be covered by insurance Costs of medical treatment (excluding medication treatments) options Costs of medical treatments (excluding medication treatments) unlikely to be covered by insurance Different costs based on location of treatment (nursing home, home, hospital) End of life care costs
☐	Whether the benefits of a given investigation/treatment/therapy merit the cost
☐	Provided the patient a list of financial resources (if necessary)
☐	Asked the patient about their concerns and preferences
☐	Confirmed the patient’s understanding of the diagnosis and treatment