37 Risk Documentation in the Laparoscopic Cholecystectomy Consent Form

Abstract

Abstract Background Laparoscopic cholecystectomy is one of the most common elective operations performed with a significant risk of complications. GMC guidance on consent clearly emphasises the process of informed consent and shared decision making. Failure to warn patients of a significant complication can lead to potential medico-legal implications. The effectiveness of the consent process is evidenced in fully completed consent form. Aim We aim to access the quality of the consent forms for Laparoscopic cholecystectomy at our institution with emphasis on the documented risks. Objectives Re-audit of quality of records of consent form documentation over one month period for laparoscopic cholecystectomy. To measure the compliance of Trust consent forms with GMC guidelines. Method Consent forms for all elective laparoscopic cholecystectomy procedures done between July and September 2020 were obtained and retrospectively analysed. The data was collected specifically from the consent forms. A total of 39 consent forms were audited. Results A total of 39 consent forms were audited. The majority of the consenting was done by registrars. As with the first phase, bleeding (100%), CBD injury (97.4%), bile leak (69.2%), infection (100%), damage to local structures (79.5%), VTE (94.9%) remained well documented in the written consent. Open conversion was present on 97.4% consent forms. 8 out of 16 risks audited showed a increase in compliance whereas 8 showed an decrease compared to the previous round of the audit phase. In particular, scarring, retained stones, pancreatitis, respiratory complications, diarrhoea, and cardiac complications showed a particularly low rate. Conclusions Risk documentation on the consent forms remains quite varied. Education combined with a standardised consent form and patient information leaflet will improve the overall quality of consent forms.