MR A EL-KHOLY Mr S SISTU Dr H VADDI

AIM OF AUDIT
To evaluate the appropriateness in filling the consent

forms. To identify and highlight the deficient areas , make changes and improve practice.

METHOD

100 ENT consent forms obtained from the medical records retrospectively and studied.

CONSENT FORM
Consent form contains two leaves . Original is filed

into notes and copy is given to patients. There are 13 items to be filled by the surgeon. They are

1) consultants name / job title. 2) Addressograph to be attached on both leaves of consent form 3) Name of the operative procedure 4)Benefits and seriously occurring risks 5) Extra procedures which may be necessary

Blood transfusion, other procedures.

6) Information leaflet for the procedure

CONSENT FORM contd...

7) Nature of anaesthetic 8) Signature, name, job title of person taking consent and date of consent 9) Patients/Parents (in case of children)name, signature and date of consent 10)Witness name, signature and date of consent 11) Interpreter's Name, signature and date. 12) copy of consent accepted by patient Yes/No 13) confirmation of consent on the day of OP by operating surgeon.

ADDRESSOGRAPH
Attached on - 97
Hand written on - 3

CONSULTANTS NAME &TITLE

NAME OF THE PROCEDURE

DISCUSSION OF BENEFITS AND SERIOUSLY OCCURING RISKS

EXTRA PROCEDURES

INFORMATION LEAFLET
76 out of 100 are routine ENT procedures with information leaflets available. 44 - recorded to have received 32 - not recorded 24 out of 100 are not routine procedures with Leaflets not available eg; Excision of thyroglossal cyst, Excision of skin lesions eg; BCC, sebaceous cysts, keloid scars, EUA PNS, EUA Ear, Tongue tie release, Removal of grommet, Removal of stone from SMG duct, Laser turbinectomy

CONFIRMATION OF CONSENT
91 confirmed on the

day of op 11 consented the same day op

PATIENT COPY
74 patients have

received the patient copy ( 40 marked, 34 not marked) 26 patients didnt receive 0 not accepted

 Nature of anaesthetic recorded in all 100

Signed by a health professional in all 100 Signed by patient in all 100

SUMMARY
Patient details , Nature of procedure, risks and

benefits, nature of anaesthetic , confirmation of consent, health professionals signature and patients signature have been recorded legibly and appropriately ON ALL 100 consent forms. 24% of patients didnt receive patient copy. In 25 /35 - extra procedures/ blood transfusion not marked Information leaflets are available for 74 / 100 . 44 / 74 were marked to have received the leaflets.

RECOMMENDATIONS
To print consultants name and job title on all consent

forms Where appropriate the extra procedures box to be ticked . Information leaflets when available to be given and marked in the consent forms for all patients. Patients copy of consent form to be given and marked in the consent form for all patients. Prepare information leaflets for uncommon procedures?