The documentation of consent is an important component of the clinical encounter. This study assesses the quality of documentation of that consent for a common surgical procedure, caesarean section, in an obstetric unit at a major teaching hospital and compares this quality between elective and emergency cases. There was a significant difference in the quality of documentation between the elective and emergency groups in some, but not all, categories assessed. Overall, the standard of consent documentation in the obstetric unit was less than desired. A proforma was designed to be included in the case notes of women undergoing caesarean section to improve the efficient and thorough documentation of consent.
Keywords: abdominal delivery; caesarean section; consent documents; documentation; informed consent.
© 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.