Abstract
Introduction Patient consent for surgery is a vital part of the surgical pathway from both a patient safety and medicolegal point of view. Improvement in documenting the full consent process in the electronic patient record (EPR), alongside the standard completion of the paper consent form in a surgical emergency unit (SEU), to comply with the Montgomery ruling of informed consent, has become of paramount importance. The aim of this project was to improve the documentation of the full consent process by creating an electronic template that was easy for the consenting clinician to use and provided a robust record of the bespoke consent process for the individual patient. Methods In July 2020, clinicians in the SEU were asked to begin documenting the patient's consent process in the EPR. The number of documented electronic consent processes (ECPs) of patients who underwent emergency general surgery during a two-week period was then captured between October and November 2020. The second cycle involved creating a single consent template, allowing the ECP to be easily documented in one template for all the common emergency surgery operations. All clinicians who were responsible for surgical consenting were asked to use the electronic template as part of the consent process. The rate of electronic consent was recorded over a second two-week period, six months later, in May 2021. Results From the first cycle, 78 patients were identified as undergoing emergency surgery, of which 13% (N=10) had an electronic entry regarding the consent process fully documented and personalised to the patient. From the second cycle, 64 patients were identified. The rate of documented ECPs increased to 77% (N=49). Conclusion This project has successfully improved the electronic demonstration of a consent process, bespoke to the individual, in accordance with the Montgomery ruling, by implementing an easy-to-use template on EPR. This is a significant step towards full digital consent in the future.