WTP8.3 Failing to record consent discussions on clinical records leaves us vulnerable

Abstract

Abstract Aims Documenting informed consent discussions in patient clinical records is a mandatory requirement by the General Medical Council (GMC). This study aimed to evaluate the adherence to that mandate. Methods We looked at GMC and Royal College of Surgeon’s guidance on consent and its documentation in patients’ records. The recommendations are: We retrospectively looked at the Electronic Patient Record (EPR) of patients admitted for surgery under the Vascular department at a tertiary centre over 3 months. We excluded patients who passed away prior to surgery or needed Consent form 4. Results 136 out of 150 patients admitted for surgery during the study period met the inclusion criteria. Of these, 90 were admitted electively and 46 as emergencies. We found evidence of consent discussion for only 60% (n-54) of the elective admissions and for 59% (n-27) of emergency admissions, through clinic letters or ward entries. For the remaining, there was no recorded EPR documentation of the consenting discussion though all had a consent form signed. Conclusions Although GMC and Royal College of surgeons have clear guidance regarding documentation of consent in patients’ notes, this is often not followed in clinical practice. This leaves the trusts open to future litigation.