This is part of the Gynsurgery surgical checklists, guidelines and informed consent used in an educational setting for residents in Ob-Gyn.
(The pdf form of this Generic Surgical Consent may not have the latest changes below)
Surgical Procedure Informed Consent
(NAME of PROCEDURE)
(DESCRIPTION OF PROCEDURE)
Reason for Procedure: ___________________________________________________
- No treatment
- Medical treatment using _________________________________________________
- Other procedural treatment _________________________________________________
I am aware of the risks of anesthesia, including the remote risk of death, heart attack, stroke or drug reactions during or after the procedure. I have been encouraged to discuss those and other anesthesia risks with the anesthesiologist prior to surgery. I know I may request a separate appointment with anesthesiology regarding my surgery, otherwise I will see my anesthesiologist in the holding area prior to being taken to the operating room.
General risks of this procedure include but are not limited to:
Nausea and dizziness from anesthesia, a sore throat, back pain, lung infection leading to pneumonia, shoulder pain for 1-2 days, (ADD OTHER COMMON COMPLICATIONS)
Infections of the incision site, urinary tract or kidney infection, bleeding, inability to complete the procedure because of scar tissue, need to complete the procedure by a larger abdominal incision, scar tissue formation in the incision or pelvis after surgery causing pain, bowel obstruction, additional surgery because of complications, later hospitalization for treatment or evaluation, (ADD OTHER SPECIFIC COMPLICATIONS)
Injury to bladder, ureter (tube from kidney to the bladder) or bowel requiring repair by immediate or later abdominal surgery (laparotomy) or (colostomy), blood vessel injury with need for transfusion, blood clots in the legs or pelvis that go to the heart or lungs (thromboembolism), nerve damage, anesthetic complications, technical difficulties to complete the planned procedure (failure of equipment, cameras, computers, etc), (ADD OTHER SPECIFIC COMPLICATIONS)
I have been encouraged to see my primary care doctor prior to procedure to discuss the present status of my health and any preventative measures, like changes in diet, lifestyle, or my medications that I might benefit from prior and after the planned surgery.
(NAME OF PROCEDURE)
- ____ I have asked all questions regarding above-mentioned complications.
- ____ I am aware that smoking during the pre- and postoperative periods could increase chances of complications especially infection and vascular problems
- ____ I am aware that having chronic medical problems (diabetes, high blood pressure, chronic lung, heart, kidney or any other long term organ disease) as well as being overweight could increase chances of complications.
- ____ I have informed the doctor of all my known allergies.
- ____ I have informed the doctor of all medications I am currently taking, including prescriptions, over-the-counter remedies, herbal therapies and supplements, aspirin, and any other recreational drug or alcohol use.
- ____ I have been advised whether I should avoid taking any or all of these medications on the days surrounding the procedure.
- ____ I am aware and accept that there are no guarantees about the results of this procedure.
- ____ I have been informed of what to expect postoperatively, including but not limited to: estimated recovery time, anticipated activity level, and the possibility of additional procedures.
- ____ I understand that any tissue/specimen removed during the surgery may be sent to pathology for evaluation.
- ____ I understand that photographs or video footage may be taken during my operation for teaching or documentation purposes (These will not identify you unless they are placed in your medical record)
My signature on this informed consent form indicates that:
- I have read and understood the information provided in this form,
- I have been verbally informed about this procedure to my satisfaction,
- I have had a chance to ask all of my questions,
- I authorize and consent to the performance of this surgery and direct
- Dr. _________________ with associates or assistants of his or her choice, to perform this procedure on me.
- I further authorize Dr. ________________ and assistants to perform any different or additional procedure(s) that in their judgment may be necessary or advisable should unforeseen circumstances arise during the procedure.
Patient signature and Date/time
Witness signature and Date/time
I have explained the nature, purpose, benefits and alternatives regarding the proposed treatment and the risks and consequences of the procedure. I have reviewed the above information with the patient and answered all of the questions to the best of my ability. I believe that the patient/legal representative fully understands what I have explained.
MD signature and Date/time