[Preoperative medical record-keeping can be improved: new informed consent form assists both physicians and patients]. / Preoperatieve dossiervoering kan beter: nieuw informed-consentformulier helpt arts én patiënt.

ABSTRACT

Adequate record-keeping is an important part of the surgical informed consent (IC) process. Standardization can enhance the quality of this process but is incomplete and qualitatively insufficiently implemented in current surgical practice. The introduction of well-designed tools would improve daily practice. We inventoried preoperative reporting at all 91 Dutch departments of General Surgery. Thirty-nine of the 73 departments that provided information on their IC process used a standard form. Twenty-nine of these forms were sent for analysis using a checklist based on legislation, recent case law and specialist literature. The mean number of items per form was 37, but not a single form was complete. Based on these results in combination with relevant legislation, guidelines and expert opinions, an adequate, user-friendly and straightforward preoperative IC form was designed. This IC form can serve as a checklist and report for the physician and as an information leaflet for the patient.