Wouter Leclercq

Preoperative medical record-keeping can be improved: New informed consent form assists both physicians and patients 145 9 THE LEGAL BASIS OF INFORMED CONSENT In the Netherlands, the Medical Treatment Contracts Act (WGBO) has been in force since 1995. 14 The WGBO also includes the rules for informed consent. Physicians must clearly inform the patient about a proposed examination or treatment and, if requested, record this in writing. 14,15 Informed consent consists of 3 components: ‘basic conditions’, ‘providing information’ and ‘consent section’ (Table 9.1). Table 9.1 Components of the preoperative informed consent. Preoperative informed consent basic conditions voluntary competence providing information diagnosis prognosis treatment options complications checking whether the information was understood consent section record of consent The basic conditions component consists of checking whether the patient is physically and mentally capable of making a well-considered and voluntary decision about their treatment (competence), without pressure from others (voluntary). The ‘providing information’ component assumes that the information is adequate, comprehensible and complete, and has also been understood by the patient. In the case of elective procedures, information about a procedure must be provided in good time, enabling the patient to process the information and, if necessary, further discuss it. The decision taken by the patient is recorded in the consent section. 2,4,14