Wouter Leclercq

Chapter 9 146 RECORDING The preoperative consultation can be recorded in various ways. In some countries, SIC standard forms, whether or not signed by the patient, are legally required (US) or highly recommended (UK and Australia). 4,9,16-18 In the Netherlands, the oral consent of the patient is usually sufficient, although the physician would do well to make a note of this consent in the file. 15,19,20 The more drastic the procedure, the more guidelines recommend that the consent be recorded in writing by making adequate notes. 2,3,14 SIC forms can serve as a checklist for the completeness of the provided information and as a reporting tool in the file. The patient receives a copy as a ‘patient leaflet’ for the operation. Earlier research showed that 26% of Dutch surgeons used SIC forms. 7 The quality of these forms often proved insufficient, due to their incompleteness, illegibility or lack of user-friendliness; studies in other Western countries showed a similar picture. 4,18,21,22 Moreover, the forms were used inconsistently, filled in incorrectly, or not checked before the intervention. 4,18,21