Abstract Aims Best practices in obtaining informed consent for surgery are outlined by RCS England guidelines and Association of Breast Surgery summary statements. Documentation of consent discussions serves as a key part of the medical record. The clinic letter, which the patient receives a copy of, ensures they have sufficient time and information to reflect upon discussions and make an informed decision. Our audit assessed adherence to best practice guidelines in the consent process for patients undergoing elective breast surgery and identified barriers impeding full compliance with standards. Methods Clinic letters of patients undergoing elective breast surgery with a prior clinic appointment at our trust over a three-month period were examined for compliance with documentation best practices. Documentation of surgical risks and consent discussions was reviewed. Data on procedure type and clinic workload metrics were also collected. Results 195 eligible cases were included. Average documentation rates of surgical risks (52%) and reference to consenting (15%) in clinic letters were highly variable between consultants. Documentation of surgical risk was higher for major surgical procedures (22%-70%). No clear relationship was observed between documentation rates of consent or surgical risk and either time to surgery or clinic workload metrics. Conclusions Our audit revealed variability in documentation practices, with discrepancies between surgical risk and consenting in clinic letters. Limitations include average time per appointment and paper documentation. We explore solutions in improving documentation, including the integration of technological consent. Template letters and refresher training will be introduced, and improvements monitored with re-audit.
Choksey et al. (Fri,) studied this question.
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