A retrospective clinical audit: Use of abbreviations in written informed consent of anaesthesia for elective oncosurgeries

Abstract

Consent form, an important legal document, is proof of communication between patient and doctor. The consent is an important process to be followed before procedure. We observed abbreviations in the anaesthesia consent forms which may result in improper understanding and communication when consenting patients for elective surgeries under anesthesia. For assessment of the quality of consent for patients, a pre-interventional audit was performed retrospectively by review of 50 anaesthesia forms for consent in our oncology center during August of 2023 for elective oncological procedures under anaesthesia. Information was collected exclusively through our institutional systems of medical record department. The data were analyzed and subsequently, a training session (in-person) was scheduled during September 2023 to highlight the value of written informed consent and to avoid abbreviations in the document. The post-interventional audit was done for during October 2023 that also included 50 anaesthesia forms for consent. The analysis of the results was performed and compared with pre-interventional results of audit. The usage of abbreviations was 44% in pre-intervention audit. It reduced to 16 % in the post-intervention audit (P value-0.0001). The abbreviations used were DM, LV, MI, PTCA, EF, STO and COPD. The most commonly used abbreviations were DM and LV in audit and DM in re-audit. A straightforward educational training intervention can improve consent quality and safety of patients and prevents likely medico-legal repercussions for institutions and persons as well involved in providing healthcare.

Keywords

• acronyms
• consent for anaesthesia
• cancer surgery