This is part 2 of the short exploration into what a consent is. Last time I discussed the signatures of the patient, of the surgeon, and of the witnessing nurse.
This time I will be discussing parts of the actual form itself.
At the top of every consent I’ve seen is the patient’s name line. This is where the patient who is going to be the surgery is written.
Underneath are two or three lines where the pre-op nurse writes down what the surgeon says the surgery is.
The nurse doesn’t write down what is their interpretation of what the surgery is. They might be wrong.
Either there is an order to obtain consent where the surgeon or PA fills out EXACTLY what is to be put on these lines. Or the surgeon writes it themselves.
As the witnessing nurse who is doing pre-op on this patient I either read what they’ve written to make sure it is what the patient is expecting or I make sure that there are no unauthorized contractions of words.
You know, and I know, that R often means right. But it might not. Laterality words must be spelled out. Other frequently contracted words are ORIF, this means open redution internal fixation. Or TAH, this means total abdominal hysterectomy. Or TKA, whic means total knee arthroplasty.
It doesn’t matter that the OR team knows what all those words mean. Because we can have complete conversations that are comprised mainly of words like LOLNAD, LOL, CHF, V-TACH, V-FIB, DNR. To me this is a bad day for the little old lady with no apparent distress who devolved into just a little old lady with congestive heart failure which devolved into ventricular tachycardia, which devolved into ventricular fibrillation, and someone reminded the team that she is do not rescuscitate. Lots of words to describe a sequence of events.
Yeah, we speak our own language.
To be legal, the patient has to understand what the words mean.
Therefore no abbreviations allowed on the procedure description lines. None.
Because if the outcome of the surgery is not what the patient expected and they sue an abbreviation can sink your defense.
Also it allows the team in the OR to be on the same page as the surgeon, the patient, the witnessing nurse.
Once upon a time before I knew better, a surgeon wrote umb. hern. They meant umbilical hernia, but the handwriting was so bad (this was before EHRs) that the tech, the charge nurse, the patient all understood it to mean right inguinal hernia. Not even remotely the same. This was caught before the patient even went back to the OR, but what if it wasn’t?
Be smart, don’t use abbreviations on your consents.
And please print! Or put the order in and someone with nice handwriting will write it out.
Dispatches from the Evening Shift 