Wouter Leclercq

Preoperative medical record-keeping can be improved: New informed consent form assists both physicians and patients 151 9 Standard Preoperative Informed Consent Form Print version * If applicable * If no: additional meeting or consultation with another physician ** If possible based on percentages Version 2.1 201312 Hospital Name and Logo Hospital location Department (e.g. surgery) Patient data Name: Date of birth: Patient number: Treating physician Name: Function: Supervisor*: General The patient demonstrates free will and gives consent without pressure from others: Yes □ No □ Information Diagnosis: Probable course with and without treatment: Suggested treatment (surgery): Other possible treatments: Reason for not recommending these: Risk of complication Common complication(s)**:    Rare but serious complication(s)**: The patient has understood the information well and is able to name the main elements: Yes □ No □ Surgeon The surgery is performed by: The treating physician □ A surgeon from the department □ No preference □ Additional information provided via: Leaflet □ Website □ Computer application □ Other □: ………………………………………………….. Consent Based on the information provided, the patient consents to the treatment described above Oral consent by patient □ Witnesses: …………………………………………………………………………. Date: xx-xx-20xx Figure 9.1A Example of a standard form for preoperative informed consent as it is printed for the patient (A: front), (See separate file for translation of informed consent form).