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Consent Audit
Auditor
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Specialty
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Audiology
Dermatology
Endoscopy
ENT
General Surgery
Gynaecology
Neurology
Ophthalmology
Radiology
Urology
Vascular Surgery
Hospital Number
*
Date
*
DD slash MM slash YYYY
Is addressograph label used?
*
Yes
No
If not, are all patient details included: name, DOB, hospital number?
*
Yes
No
N/A
Do details match details on medical records?
*
Yes
No
Is procedure appropriately documented
*
Yes
No
Are there any abbreviations?
*
Yes
No
Please list any abbreviations
Is it legible
*
1
2
3
4
5
1 = Illegible 2 = Slightly illegible 3 = Satisfactory 4 = Slightly readable 5 = Easy to read
Is the terminology used patient friendly or not (for example ‘Keyhole’ rather than ‘laparoscopic’)
*
Yes
No
Intended benefits - is this completed?
*
Yes
No
Risks/Complications of procedure documented
*
Yes
No
Extra procedures – is this completed on consent form
*
Yes
No
Indicate type of anaesthetic may/will be involved – LA, GA, Sedation – is this completed
*
Yes
No
Please include the type of Anaesthetic used:
*
Consent Form signed (staff)
*
Yes
No
Name printed (staff)
*
Yes
No
Is the job title of the person documenting consent indicated
*
Yes
No
Job title of person documenting consent:
Dated (staff)
*
Yes
No
Patient signed
*
Yes
No
Patient name printed
*
Yes
No
Patient signature dated
*
Yes
No
Additional Comments
