Completion of hand-written surgical consent forms is frequently suboptimal and could be improved by using electronically generated, procedure-specific forms. Issue 4 (August 2017)

• Record Type: Journal Article
• Authors: St John, E.R.; Scott, A.J.; Irvine, T.E.; Pakzad, F.; Leff, D.R.; Layer, G.T.
• Is Part Of: Surgeon. Volume 15:Issue 4(2017)
• Page Start: 190
• Page End: 195
• Publication Date: 2017-08
• Subjects: Consent -- Consent forms -- Surgery -- Medical informatics; Surgery -- Periodicals; Surgery -- Periodicals; Surgical Procedures, Operative -- Periodicals; 617
• DOI: 10.1016/j.surge.2015.11.004
• Languages: English
• ISSNs: 1479-666X

Abstract

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.