{"$schema":"https://json-schema.org/draft/2020-12/schema","title":"Record of consent or refusal of care — Consignation du consentement ou du refus de soins / Vastlegging van toestemming of weigering van zorg (BE)","description":"Written record, on the request of the patient or of the healthcare professional, of the patient's consent, refusal or withdrawal of consent to an intervention (law of 22 August 2002 on patients' rights, arts 8 and 8/1): professional, patient, who decides, the intervention, the information given as the professional states it, the decision and its date, signatures, the addition to the patient file. No capacity verdict, no waiver, no national register number; nothing is defaulted.","type":"object","additionalProperties":false,"required":["document","professional","patient","decision_by","intervention","information","decision","signatures"],"properties":{"document":{"type":"object","additionalProperties":false,"description":"The record itself.","properties":{"date":{"type":"string","format":"date","description":"Date on which the record is drawn up."},"place":{"type":"string","description":"Place where the record is drawn up."}},"required":["date"]},"professional":{"type":"object","additionalProperties":false,"description":"The healthcare professional.","properties":{"name":{"type":"string","description":"Name of the professional."},"profession":{"type":"string","description":"Profession (physiotherapist, dentist, nurse, doctor, psychologist, midwife)."},"inami_number":{"type":"string","description":"INAMI / RIZIV number of the professional."},"address":{"type":"string","description":"Address of the practice."},"enterprise_number":{"type":"string","pattern":"^[01][0-9]{3}\\.[0-9]{3}\\.[0-9]{3}$","description":"Belgian enterprise number of the practice, if any."},"seat_region":{"type":"string","enum":["nl_region","fr_region","brussels","de_region"],"description":"Linguistic region of the operating seat (language rules)."}},"required":["name","profession","address"]},"patient":{"type":"object","additionalProperties":false,"description":"The patient.","properties":{"name":{"type":"string","description":"Name of the patient."},"birth_date":{"type":"string","format":"date","description":"Date of birth of the patient."},"address":{"type":"string","description":"Address of the patient."}},"required":["name"]},"decision_by":{"type":"string","enum":["patient","representative","patient_with_confidential_person"],"description":"Who decides: the patient, the representative of chapter IV, or the patient with a confidential person present. A minor judged apt to appreciate his interests reasonably decides alone (art. 12 § 2) and is entered as patient. Nothing is asserted about capacity."},"representative":{"type":"object","additionalProperties":false,"description":"The representative (chapter IV).","properties":{"name":{"type":"string","description":"Name of the representative."},"capacity_stated":{"type":"string","description":"Capacity as stated (for example parent, mandated person)."}},"required":["name"]},"confidential_person":{"type":"object","additionalProperties":false,"description":"The confidential person who assists the patient.","properties":{"name":{"type":"string","description":"Name of the confidential person."}},"required":["name"]},"intervention":{"type":"object","additionalProperties":false,"description":"The intervention concerned.","properties":{"name":{"type":"string","description":"Name of the intervention."},"planned_date":{"type":"string","format":"date","description":"Planned date of the intervention."},"place":{"type":"string","description":"Place of the intervention."},"urgency_stated":{"type":"string","description":"Degree of urgency as the professional states it."}},"required":["name"]},"information":{"type":"object","additionalProperties":false,"description":"The information given to the patient before the decision (art. 8 § 2 of the law of 22 August 2002).","properties":{"waived_by_patient":{"type":"boolean","description":"Whether the patient expressly asked not to receive the information (art. 7 § 3); when true the five items below are not required."},"objective_nature":{"type":"string","description":"Objective, nature and degree of urgency of the intervention, as the professional states them (art. 8 § 2, 1°)."},"duration_frequency":{"type":"string","description":"Duration and frequency of the intervention (art. 8 § 2, 1°); 'not applicable' is a valid answer."},"expected_course_follow_up":{"type":"string","description":"Probable developments and follow-up care (art. 8 § 2, 2°)."},"contraindications_side_effects_risks":{"type":"string","description":"Contraindications, side effects and risks relevant to the patient (art. 8 § 2, 3°)."},"alternatives":{"type":"string","description":"Possible alternatives, carried out or not by another professional (art. 8 § 2, 4°)."},"other_relevant":{"type":"string","description":"Other clarifications relevant to the patient, including legal provisions to respect (art. 8 § 2, 5°)."},"financial_consequences":{"type":"string","description":"Financial consequences of the intervention, as the professional states them (art. 8 § 2, al. 3); the amounts as stated."},"written_copy_given":{"type":"boolean","description":"Whether the information was also given in writing (art. 7 § 2)."},"questions_invited":{"type":"boolean","description":"Whether the patient was invited to ask questions (art. 7 § 2)."},"language":{"type":"string","description":"Language in which the information was given."}},"required":["waived_by_patient"],"allOf":[{"if":{"properties":{"waived_by_patient":{"const":false}},"required":["waived_by_patient"]},"then":{"required":["objective_nature","expected_course_follow_up","contraindications_side_effects_risks","alternatives","financial_consequences"]}}]},"decision":{"type":"object","additionalProperties":false,"description":"The decision of the patient and the refusal details.","properties":{"kind":{"type":"string","enum":["consent","refusal","withdrawal"],"description":"consent, refusal or withdrawal of the consent (arts 8 and 8/1)."},"scope":{"type":"string","description":"Whether the decision covers the whole intervention or a part, as the professional records it."},"date":{"type":"string","format":"date","description":"Date on which the patient decided."},"requested_by":{"type":"string","enum":["patient","professional"],"description":"Who asked for the written record: the patient or the professional."},"consequences_explained":{"type":"string","description":"Possible consequences of the refusal or withdrawal that were explained (art. 8/1, al. 3); required for a refusal or a withdrawal."},"alternatives_discussed":{"type":"string","description":"Alternative interventions discussed with the patient (art. 8/1, al. 3); required for a refusal or a withdrawal."},"right_to_quality_care_noted":{"type":"boolean","description":"Whether the record notes that the refusal or withdrawal does not end the right to quality care (art. 8/1, last sentence)."}},"required":["kind","date"],"allOf":[{"if":{"properties":{"kind":{"enum":["refusal","withdrawal"]}},"required":["kind"]},"then":{"required":["consequences_explained","alternatives_discussed"]}}]},"signatures":{"type":"object","additionalProperties":false,"description":"Signatures.","properties":{"patient_or_representative":{"type":"object","additionalProperties":false,"description":"Signature of the patient or of the representative.","properties":{"name":{"type":"string","description":"Name of the signatory."},"date":{"type":"string","format":"date","description":"Date of the signature."}},"required":["name"]},"professional":{"type":"object","additionalProperties":false,"description":"Signature of the professional.","properties":{"name":{"type":"string","description":"Name of the signatory."},"date":{"type":"string","format":"date","description":"Date of the signature."}},"required":["name"]}},"required":["patient_or_representative","professional"]},"file":{"type":"object","additionalProperties":false,"description":"The patient file.","properties":{"added_on":{"type":"string","format":"date","description":"Date on which the record is added to the patient file."},"copy_to_patient":{"type":"boolean","description":"Whether a copy was given to the patient."}}}},"allOf":[{"if":{"properties":{"decision_by":{"const":"representative"}},"required":["decision_by"]},"then":{"required":["representative"]}},{"if":{"properties":{"decision_by":{"const":"patient_with_confidential_person"}},"required":["decision_by"]},"then":{"required":["confidential_person"]}}]}