Demonstrating the Electronic Consent Process for Emergency Surgical Patients.

Area of Science:

• Medical Informatics
• Surgical Patient Safety
• Informed Consent Law

Background:

• Patient consent is critical for surgical safety and medicolegal compliance.
• Documenting informed consent in electronic patient records (EPR) is crucial, especially in surgical emergency units (SEU).
• The Montgomery ruling emphasizes the need for bespoke, documented consent processes.

Purpose of the Study:

• To improve the documentation of the surgical informed consent process within the EPR.
• To develop an easy-to-use electronic template for recording bespoke patient consent.
• To enhance the robustness of consent records for individual patients.

Main Methods:

• Clinicians in an SEU were instructed to document patient consent in the EPR.
• An initial two-week period (Oct-Nov 2020) captured baseline electronic consent process (ECP) rates.
• A standardized electronic consent template was implemented, and ECP rates were reassessed over a subsequent two-week period (May 2021).

Main Results:

• In the initial phase, only 13% (10/78) of emergency general surgery patients had fully documented ECPs.
• Following the implementation of a standardized electronic template, the rate of documented ECPs increased to 77% (49/64).
• The electronic template facilitated easier and more comprehensive documentation of the consent process.

Conclusions:

• Implementing an easy-to-use electronic template significantly improves the electronic demonstration of bespoke patient consent.
• This initiative enhances compliance with informed consent rulings like Montgomery.
• The project represents a substantial advancement towards fully digital consent processes in healthcare.