Wouter Leclercq

Preoperative medical record-keeping can be improved: New informed consent form assists both physicians and patients 147 9 CURRENT PRACTICE In April and May 2011, we conducted a survey by e-mail and telephone, asking surgeons and surgical residents from all 91 general surgery departments in the Netherlands whether they used a standard pre-operative form. If such a form was available, they were asked to send a copy - hardcopy or digital. Forms for specific procedures or emergency surgery were excluded. In the absence of a reaction, repeated requests were sent. We finalised the data collection at the end of 2011. A checklist was drawn up on the basis of the WGBO and the guideline ‘The preoperative process’ of the Quality Institute for Healthcare CBO. Based on this checklist, the submitted reports were assessed for quality. Of the 91 surgical departments, 73 (80%) responded; 18 departments refused to cooperate or did not respond. A small majority (39 out of 73, 53%) used a standardised SIC report. 29 departments sent us an example of their preoperative report (see the supplement to this article). The forms were very diverse and often incomplete. The average number of data recorded was 37 (extremes: 3-205). Basic data such as date (83%), hospital (66%), patient (86%) and physician (72%) were usually present, but remarkably few forms mentioned items such as indication (52%), prognosis (21%) or other possible treatment options (7%). 69% of the forms stated that consent for surgery had been obtained. 28% required a signature by the physician and/or patient.