Wouter Leclercq

Preoperative medical record-keeping can be improved: New informed consent form assists both physicians and patients 143 9 INTRODUCTION Good file management is an important part of the preoperative informed consent process. Standardisation could improve the quality of this process, but currently it is incomplete and inadequately implemented. The introduction of good, practical tools could improve daily practice. We have inventoried the preoperative recording for the 91 surgical departments in the Netherlands. Of the 73 departments that responded, 39 indicated they used a standard form. 29 of these forms were sent in for analysis. These documents were assessed using a checklist based on legislation, recent case law and professional literature. On average, the forms listed 37 different data. However, none of the forms was complete. On the basis of this inventory and taking into account legislation, literature and expertise in the field, we designed a standard form that records preoperative informed consent in a legally adequate, user-friendly and clear manner. This form can serve both as a checklist and reporting tool for the physician, and as a ‘leaflet’ for the patient. All physicians must keep their records up to date. 1 In the case of major events such as surgery, the need for adequate reporting may be even greater. 2 The report should reflect what has been discussed with the patient and which choices the patient has made. 1-3 This is the summary of the preoperative surgical informed consent process (SIC) that the physician and patient have discussed together. 1-4 This process guarantees the autonomy of a patient who has to undergo invasive surgery and helps the patient to make an informed decision about the treatment. To date, there are no generally accepted standard forms for recording the preoperative consultation in the Netherlands. We believe that a legally adequate, user-friendly and above all practical standard form for preoperative informed consent would be a major step forward.