cystoscopy and urethrotomy - Pchurology.co.uk

CONSENT FORMforUROLOGICAL SURGERY(Designed in compliance with consent form 1)PATIENT AGREEMENT TOINVESTIGATION OR TREATMENTPatient Details or pre-printed labelPatient’s NHS Number or HospitalnumberPatient’s surname/family namePatient’s first namesDate of birthSexResponsible health professionalJob TitleSpecial requirementse.g. other language/other communicationmethod1

Patient identifier/labelName of proposed procedure(Include brief explanation if medical term not clear)(Rigid ) CYSTOSCOPY AND OPTICAL INTERNAL URETHROTOMYTHIS PROCEDURE INVOLVES TELESCOPIC INSPECTION OF URETHRA AND BLADDER AND TO INCISEA STRICTURE WITH A TELESCOPIC KNIFE OR LASER.ANAESTHETIC- GENERAL/REGIONAL- LOCAL- SEDATIONStatement of health professional (To be filled in by health professional withappropriate knowledge of proposed procedure, as specified in consent policy) I have explainedthe procedure to the patient. In particular, I have explained:The intended benefitsRELIEF OF OBSTRUCTION TO FLOW OF URINESerious or frequently occurring risks including any extra procedures, which may becomenecessary during the procedure. I have also discussed what the procedure is likely to involve, thebenefits and risks of any available alternative treatments (including no treatment) and any particularconcerns of this patient. Please tick the box once explained to patientCOMMON MILD BURNING OR BLEEDING ON PASSING URINE FOR SHORT PERIOD AFTER OPERATION TEMPORARY INSERTION OF A CATHETER NEED FOR SELF CATHETERISATION TO KEEP THE NARROWING FROM CLOSING DOWN AGAINOCCASIONAL INFECTION OF BLADDER REQUIRING ANTIBIOTICS PERMISSION FOR TELESCOPIC REMOVAL/ BIOPSY OF BLADDER ABNORMALITY/STONE IF FOUND RECURRENCE OF STRICTURE NECESSITATING FURTHER PROCEDURES OR REPEAT INCISIONRARE RARELY, DECREASE IN QUALITY OF ERECTIONS REQUIRING TREATMENTALTERNATIVE THERAPY: OBSERVATION, URETHRAL DILATION, OPEN (NON-TELESCOPIC) REPAIR OF STRICTUREA blood transfusion may be necessary during procedure and patient agrees YES or NO (Ring)Signature ofHealth ProfessionalPrinted NameJob TitleDateThe following leaflet/tape has been providedContact details (if patient wishes to discuss options later) _____________________________________Statement of interpreter (where appropriate) I have interpreted the information above to thepatient to the best of my ability and in a way in which I believe s/he can understand.Signature ofinterpreter:Copy (i.e. page 3) accepted by patient: yes/no (please ring)Print name:Date:2

Patient identifier/labelName of proposed procedure(Include brief explanation if medical term not clear)((Rigid ) CYSTOSCOPY AND OPTICAL INTERNAL URETHROTOMYTHIS PROCEDURE INVOLVES TELESCOPIC INSPECTION OF URETHRA AND BLADDER AND TO INCISE ASTRICTURE WITH A TELESCOPIC KNIFE OR LASER.Patient CopyANAESTHETIC- GENERAL/REGIONAL- LOCAL- SEDATIONStatement of health professional (To be filled in by health professional withappropriate knowledge of proposed procedure, as specified in consent policy) I have explainedthe procedure to the patient. In particular, I have explained:The intended benefitsRELIEF OF OBSTRUCTION TO FLOW OF URINESerious or frequently occurring risks including any extra procedures, which may becomenecessary during the procedure. I have also discussed what the procedure is likely to involve, thebenefits and risks of any available alternative treatments (including no treatment) and any particularconcerns of this patient. Please tick the box once explained to patientCOMMON MILD BURNING OR BLEEDING ON PASSING URINE FOR SHORT PERIOD AFTER OPERATION TEMPORARY INSERTION OF A CATHETER NEED FOR SELF CATHETERISATION TO KEEP THE NARROWING FROM CLOSING DOWN AGAINOCCASIONAL INFECTION OF BLADDER REQUIRING ANTIBIOTICS PERMISSION FOR TELESCOPIC REMOVAL/ BIOPSY OF BLADDER ABNORMALITY/STONE IF FOUND RECURRENCE OF STRICTURE NECESSITATING FURTHER PROCEDURES OR REPEAT INCISIONRARE RARELY, DECREASE IN QUALITY OF ERECTIONS REQUIRING TREATMENTALTERNATIVE THERAPY: OBSERVATION, URETHRAL DILATION, OPEN (NON-TELESCOPIC) REPAIR OF STRICTUREA blood transfusion may be necessary during procedure and patient agrees YES or NO (Ring)Signature ofHealth ProfessionalPrinted NameJob TitleDateThe following leaflet/tape has been providedContact details (if patient wishes to discuss options later) _____________________________________Statement of interpreter (where appropriate) I have interpreted the information above to thepatient to the best of my ability and in a way in which I believe s/he can understand.Signature ofinterpreter:Print name:Date:3

Statement of patientPatient identifier/labelPlease read this form carefully. If your treatment has been planned in advance, youshould already have your own copy of page 2, which describes the benefits and risks ofthe proposed treatment. If not, you will be offered a copy now. If you have any furtherquestions, do ask – we are here to help you. You have the right to change your mind atany time, including after you have signed this form.I agreeI understand• to the procedure or course of treatment described on this form.• to a blood transfusion if necessary• That any tissue that is normally removed in this procedure could be storedand used for medical research (after the pathologist has examined it) ratherthan simply discarded. PLEASE TICK IF YOU AGREE• that you cannot give me a guarantee that a particular person will perform theprocedure. The person will, however, have appropriate experience.• that I will have the opportunity to discuss the details of anaesthesia with ananaesthetist before the procedure, unless the urgency of my situationprevents this. (This only applies to patients having general or regionalanaesthesia.)• that any procedure in addition to those described on this form will only becarried out if it is necessary to save my life or to prevent serious harm to myhealth.• about additional procedures which may become necessary during mytreatment. I have listed below any procedures which I do not wish to becarried out without further discussion.__________________________________________________________________________________________Signatureof Patient:XPrintplease:Date:A witness should sign below if the patient is unable to sign but has indicated his orher consent. Young people/children may also like a parent to sign here. (See DOH guidelines).Signed____________________________Date______________________________Name (PRINT) _____________________Confirmation of consent (to be completed by a health professional when the patientis admitted for the procedure, if the patient has signed the form in advance). On behalf of theteam treating the patient, I have confirmed with the patient that s/he has no further questionsand wishes the procedure to go ahead.Signature ofHealth ProfessionalPrinted NameJob TitleDateImportant notes: (tick if applicable). See also advance directive/living will (eg Jehovah’s Witness form). Patient has withdrawn consent (ask patient to sign/date here)4