Bharathan Rasiah, Rawesh Rebecca, Ahmed Hasib
Department of Obstetrics and Gynaecology, Medway Maritime Hospital, Gillingham, UK.
J Fam Plann Reprod Health Care. 2009 Jul;35(3):177-9. doi: 10.1783/147118909788707823.
To analyse the completeness of written consent for laparoscopic tubal occlusion and to consider the medico-legal implications of incomplete written consent.
A retrospective review was undertaken of the medical records of all women who had laparoscopic tubal occlusion in 2006 in a district general hospital to elicit details of risks of the procedure as recorded on the consent form. The extent of documentation of risks and complications that were cited in the guidelines was analysed. In addition, the grade of doctor and the timing of obtaining written consent were studied.
A total of 267 women underwent laparoscopic tubal occlusion and 214 (80.1%) case notes were reviewed in the present study. The findings demonstrate wide variation in the description of risks by doctors of different grades. The majority of written consents (65.9%) were obtained on the day of surgery. In most cases (75.2%) trainees were responsible for obtaining written consent.
Although the written consent form is a legally effective document, the process of documentation is inconsistent and this may leave the senior gynaecologist in a vulnerable position.
分析腹腔镜输卵管闭塞书面同意书的完整性，并探讨不完全书面同意书的法医学意义。
对一家地区综合医院2006年所有接受腹腔镜输卵管闭塞手术的女性病历进行回顾性研究，以获取同意书上记录的手术风险细节。分析指南中提及的风险和并发症的记录程度。此外，研究医生的级别以及获得书面同意的时间。
共有267名女性接受了腹腔镜输卵管闭塞手术，本研究审查了214份（80.1%）病历。结果显示不同级别医生对风险的描述差异很大。大多数书面同意书（65.9%）是在手术当天获得的。在大多数情况下（75.2%），实习医生负责获取书面同意书。
虽然书面同意书是一份具有法律效力的文件，但记录过程并不一致，这可能使高级妇科医生处于易受伤害的境地。
