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Surgeon. 2017 Aug;15(4):190-195. doi: 10.1016/j.surge.2015.11.004. Epub 2016 Jan 11.

Completion of hand-written surgical consent forms is frequently suboptimal and could be improved by using electronically generated, procedure-specific forms.

Author information

1
Academic Surgical Unit, Division of Surgery and Cancer, Imperial College London, St Mary's Hospital, Paddington, London, UK. Electronic address: edward.stjohn@imperial.ac.uk.
2
Academic Surgical Unit, Division of Surgery and Cancer, Imperial College London, St Mary's Hospital, Paddington, London, UK; Division of Surgery, Imperial College Healthcare NHS Trust, St Mary's Hospital, Paddington, London, UK.
3
Department of Breast Surgery, Royal Surrey County Hospital, Guildford, UK.
4
Department of Breast Surgery, Royal Surrey County Hospital, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK.

Abstract

INTRODUCTION:

Completion of hand-written consent forms for surgical procedures may suffer from missing or inaccurate information, poor legibility and high variability. We audited the completion of hand-written consent forms and trialled a web-based application to generate modifiable, procedure-specific consent forms.

METHODS:

The investigation comprised two phases at separate UK hospitals. In phase one, the completion of individual responses in hand-written consent forms for a variety of procedures were prospectively audited. Responses were categorised into three domains (patient details, procedure details and patient sign-off) that were considered "failed" if a contained element was not correct and legible. Phase two was confined to a breast surgical unit where hand-written consent forms were assessed as for phase one and interrogated for missing complications by two independent experts. An electronic consent platform was introduced and electronically-produced consent forms assessed.

RESULTS:

In phase one, 99 hand-written consent forms were assessed and the domain failure rates were: patient details 10%; procedure details 30%; and patient sign-off 27%. Laparoscopic cholecystectomy was the most common procedure (7/99) but there was significant variability in the documentation of complications: 12 in total, a median of 6 and a range of 2-9. In phase two, 44% (27/61) of hand-written forms were missing essential complications. There were no domain failures amongst 29 electronically-produced consent forms and no variability in the documentation of potential complications.

CONCLUSION:

Completion of hand-written consent forms suffers from wide variation and is frequently suboptimal. Electronically-produced, procedure-specific consent forms can improve the quality and consistency of consent documentation.

KEYWORDS:

Consent; Consent forms; Medical informatics; Surgery

PMID:
26791394
DOI:
10.1016/j.surge.2015.11.004
[Indexed for MEDLINE]

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