Standards for general practices

Core module

Criterion C1.3 – Informed patient decisions

        1. Criterion C1.3 – Informed patient decisions

Last revised: 24 Feb 2023



C1.3 A Our patients receive information about proposed investigations, referrals and treatments, including their purpose, importance, benefits, and risks.

C1.3 B Our patients receive information to support the diagnosis, treatment, and management of their conditions.

Why this is important

Patients have the right to make informed decisions about their health, medical treatments, referrals and procedures. You have a duty to provide information that the patient can understand, and that is tailored to their individual needs.

Meeting this Criterion

Providing appropriate and sufficient information

Practitioners can provide information verbally to patients during a consultation. When explaining proposed investigations, referrals and treatments to patients, deliver the information in an appropriate language and format. This means using simple language, minimising jargon and complicated terms, and using clear diagrams. When delivering information to a patient, consider:

  • the patient’s physical, visual and cognitive capacities that may affect their ability to understand the information, make decisions or provide consent
  • the most appropriate way to communicate potentially sensitive information (eg about sexually transmitted infections, blood-borne viruses and pregnancy results)
  • the patient’s cultural and linguistic background (eg you may need to use an interpreter to check that the patient understands everything that you have told them)
  • the patient’s family members who are involved in their care (with consent of the patient where the patient has capacity)
  • the patient’s level of health literacy and therefore their ability to understand the information
  • managing the amount of information you give to avoid overwhelming them.

All of these factors must also be considered if you need to give information to a carer.

Further information provided to patients and carers can be paper-based or online (eg leaflets, brochures and links to reputable websites).

It is appropriate to discuss with patients the option of no treatment. Practitioners can explain the advantages and disadvantages of different treatment approaches in conversation with patients. Unnecessary tests and treatments can be painful and dangerous, carrying a risk of complication that can affect quality of life or, in extreme cases, trigger a life-threatening problem.

Information about interventions

Receiving information about tests and treatments (including medicines and medicine safety) may help patients to make informed decisions about their care. For this reason, practitioners need to:

  • check the patient’s understanding about the intervention
  • check the carer’s understanding of the intervention, if the patient has a carer
  • offer to discuss any issues about a patient’s condition, proposed treatment and medicines that could be confusing
  • direct patients to reliable health and medicine websites where they can find further information
  • recommend that patients seek further advice about their medicines from their pharmacist.

Health literacy

Individual health literacy is defined by the Australian Commission on Safety and Quality in Health Care (ACSQHC) as ‘the skills, knowledge, motivation and capacity of a person to access, understand, appraise and apply information to make effective decisions about health and healthcare and take appropriate action’.3

Health literacy plays an important role in enabling effective partnerships between practitioners and patients. For partnerships to work, everyone involved needs to be able to give, receive, interpret and act on information, such as treatment options and plans.

Assessing the health literacy of patients and then providing them with information based on that assessment can help you to increase a patient’s awareness and understanding of their diagnosis, condition, treatment options and the possible risks or side effects of medications or treatments.

Practitioners can build a patient’s health literacy by:

  • recognising the patient’s needs and preferences and tailoring communication accordingly
  • assuming that most people will have difficulty understanding complex health information and concepts
  • providing health information in an unrushed manner using words that the patient understands
  • using multiple forms of communication to confirm that information has been delivered and received effectively
  • giving the patient targeted information (eg leaflets) and telling them where they can access targeted information (eg websites and online support groups)
  • encouraging the patient, carer and other relevant parties to say if they have difficulty understanding the information
  • using proven methods of informing patients about the risks of treatment options.

Meeting each Indicator

C1.3 A Our patients receive information about proposed investigations, referrals and treatments, including their purpose, importance, benefits, and risks.

You must:

  • obtain patient consent for a third party (eg an interpreter) to be present at consultations when the patient needs help understanding their health information
  • have a process which ensures that patients understand the information.

You could:

  • use diagrams or flip charts in consultations to help explain health matters to patients
  • use tools that help the practitioner and the patient to share the decision making, and establish a supportive and effective partnership
  • provide patients with the information they need to understand and manage their health, such as paper copies of information sheets and names and URLs of reputable websites.

C1.3 B Our patients receive information to support the diagnosis, treatment, and management of their conditions.

You must:

  • document in the patient’s health record the treatment options and associated risks and side effects that you have explained and discussed with the patient
  • document in the patient’s health record the patient’s refusal to obtain or follow any clinician’s advice.

You could:

  • provide patients with information sheets and instructions about relevant health conditions, treatments and medicines
  • make available a range of health information sheets that are one to two pages long
  • have information relating to culturally specific health information (eg Aboriginal and Torres Strait Islander health) in the waiting room and consultation rooms
  • display posters containing information about specific diseases, such as diabetes and chicken pox.