Abstract

Abstract Aim Consent documentation for surgical procedures must be precise and clear in order to achieve excellence in clinical practice. In this audit, we aim to compare our consent forms against BAUS information leaflets on ureteroscopy and stone procedure and assess the documentation of all serious and frequently occurring complications as mentioned on BAUS leaflet. Method We retrospectively reviewed the consent forms of 60 patients who underwent elective ureteroscopy between August 2020 - April 2021 to assess the quality of documentation as well as legibility of handwriting. Results As a total of 60 consent forms were reviewed. 35 males and 25 females contributed to the study with 59 being the median age. There were over 10 risks being commonly missed. Some of the important risks such as stone recurrence 95%, catheterisation 92%, major damage to ureter wall 86%, pain 71% and residual stone 61% were missed. The documentation also outlines other risks; ureteric stricture 53%, aesthetic risk 67%, failure to access ureter 51% and stent symptoms 47%. Minor damage to the wall of ureter 41%, alongside need of another surgery were recorded as other commonly neglected risks. However, only 7% of the consent forms did not mention bleeding and just 2% of the forms failed to include stent insertion as a common effect of procedure. Only 17% consent for did not have eligible handwriting, although this is subjective. Conclusions Documentation on consent forms for ureteroscopy lacks accuracy and missed important information. We propose use of digital consent form to assess compliance and quality of consent documentation.

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