Detailed consent forms improve documentation of the consent process: a prospective audit

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AimTo evaluate the effect of introducing new detailed consent forms, with a dedicated section prompting the recording of risks and complications discussed, on written documentation of the consent process, and to determine which members of the surgical team obtained consent.MethodsThe consent forms and associated medical case notes of 84 consecutive general surgical inpatients were evaluated, 44 prior to (Group 1), and 40 following (Group 2), the introduction of a new detailed consent form. Documentation of patient details, the planned surgical procedure, the patients’ and surgeons’ signatures, and discussion of attendant risks and possible complications were noted.ResultsIntroduction of the new form resulted in a significant improvement in the written documentation of any risks and possible complications when compared to the original forms (mean difference 20.0, ±95% CI ±18.3%).ConclusionsConsent forms designed with specific fields for recording discussion of risks and possible complications improve written documentation of the consent process.

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