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Adult Social Care Digital Social Care Record: Minimum Operational Data Standard (MODS): Implementation Guidance

Consent and legal information (page 18 of 9) in Conceptual Model: Adult Social Care Record (chapter 8 of 10) within Adult Social Care Digital Social Care Record: Minimum Operational Data Standard (MODS): Implementation Guidance

Records of informed consent and legal information for a person’s care.

%%{ init: { 'theme': 'base' } }%% graph TD accTitle: visualisation of a conceptual data model for Consent and legal information accDescr: Everything in your care starts with your permission, which is often called giving informed consent. You are at the heart of every decision, but you can also have a trusted person—like a legal proxy or someone with power of attorney—help make choices for you if you are ever unable to do so yourself. There are also special documents used to record your specific wishes ahead of time, such as how you want to be treated in an emergency or if you want to refuse certain medical treatments. The most important rule shown here is that your clear agreement is required before your care team can start a new care plan, carry out health tests, or follow specific instructions. This process ensures you stay in control of your health and that your personal choices are always respected. %% Top Level Legal/Professional Entities CA[Care Actor] Sub[Subject of Care] Proxy[Subject of Care Proxy] LPA[Lasting Power of Attorney] IC[Informed Consent] %% Legal Documents (Left and Right) DoLS[DoLS] ADRT[Advanced Decision to Refuse Treatment] CPR[CPR Decision] AS[Advanced Statement] MHA[Mental Health Act or Equivalent] %% Organizational Logic CA -- "1 assigns 0..*" --> LPA LPA -- "0..* is assigned to 1" --> Sub LPA --- Proxy Sub -- "1 has 0..*" --> DoLS Sub -- "1 concerns 0..*" --> ADRT Sub -- "1 concerns 0..*" --> CPR Sub -- "1 concerns 0..*" --> AS Sub -- "1 concerns 0..*" --> MHA Sub -- "1 states 0..*" --> IC Proxy -- "1 states 0..*" --> IC %% Consented Processes subgraph Processes [Processes Requiring Consent] direction LR Ass[Assessment] ~~~ Inst[Instruction] ~~~ Actn[Action] ~~~ Actv[Activity] ~~~ CP[Care Plan] end IC -- "0..1 requires 0..*" --> Ass IC -- "0..1 requires 0..*" --> Inst IC -- "0..1 requires 0..*" --> Actn IC -- "0..1 requires 0..*" --> Actv IC -- "0..1 requires 0..*" --> CP

Records of legal information include:

Advance decision to refuse treatment (ADRT) Advance statement Cardio-pulmonary resuscitation Deprivation of Liberty Safeguards (DoLS) or equivalent Lasting power of attorney Mental Health Act or Equivalent Lasting power of attorney is assigned by a Care Actor to an attorney who can act as a Proxy for subject of care.

A record of Informed consent is required for:

Assessments Care plans Instructions Activities and Actions Informed consent can be given or refused by the Subject of care, or if the Subject of care does not have Mental Capacity the Proxy for subject of care is required to give or refuse Informed Consent.

Page last updated: 13 July 2026