Coastal Carolina Hospital Surgical Consent Form

CCD Informed Consent for Surgery – J. Hatch MD FRCSC
Please take a few minutes to carefully read the attached forms.
The attached material written by me contains a detailed explanation of the pertinent
risks and benefits of your surgery as well as listing alternatives to the proposed surgery.
The risks or complications which I consider to be of greatest concern for you personally
are in bold type, highlighted, underlined or circled.
Paragraph 4 describes the more frequent, but minor potential side effects, minor
complications and lesser risks which are specific to you as a patient undergoing the
surgery I am recommending. Most people will never experience these risks but they
definitely occur in some patients and have been reported by most surgeons even in the
best of circumstances.
Pay special attention to the Specific Risks for your surgery at the end of Paragraph 4.
Paragraph 5 lists severe but quite rare events that I often refer to as the “I-95
complications”. By this I mean you to consider the risks driving down the Interstate.
While traveling, there is always the very slight possibility that another car could lose
control and crash into you. Yet, when you started the trip, you really didn’t imagine that
as a likely event. Think of the risks of your surgery listed in paragraph 5 as you might the
interstate journey – possible but not expected.
Pay special attention to the Specific Risks for your surgery at the end of Paragraph 5.
Please also remember as you read this list of complications that this consent form is
used for patients of all ages and stages in life so that the risks if you are young and
healthy are very different, less severe and less likely than if you might be at an
advanced age or diagnosed with multiple, potentially life-shortening medical illnesses.
After you have a chance to read this information, I would like to answer any questions or
concerns you may have.
Feel free to call me you before you sign this form (843) 682-7480.
Once I have answered your questions addressed any concerns you may have, the
Coastal Carolina Hospital staff will witness your signature on the hospital consent form
after you have had an opportunity to meet with your anesthesiologist.
CCD Informed Consent for Surgery – J. Hatch MD FRCSC
1. My illness or condition has been explained to me as:
2. Alternate ways to treat my medical problem have been explained to me as:
 Non-Operative Treatment: medications, injections, splints, casts
 Operative Treatment : manipulation and casting, percutaneous pinning (pins
drilled into the bone through skin punctures) external fixation (the pins in each
bone are connected together by a rigid tubular frame just above the skin
 Open Surgery: (traditional skin incision often with implants, plates and screws)
3. The procedure recommended by Dr. Hatch is:
4. More frequent but minor risks of the planned procedure generally include:
 pain, persistent swelling/numbness around or below the incision
 tethering of the tendons at the operative site, stiffness of the adjacent joints
 prominent or unsightly implants (if used)
 superficial wound infection at the incision, pin tract infection
Specific Minor Risks:
5. Rare, very serious risks of the planned procedure generally include:
 injury to the arteries & veins
 compartment syndrome (swelling blocks off the blood supply to the limb)
 permanent nerve damage resulting in weakness or paralysis of the limb
 blood clots in the legs (DVT-deep vein thrombosis) or lungs (PE-lung embolism)
 joint dislocation or tendon rupture requiring surgical repair
 degenerative arthritis due to premature wear of the joint surface
 deep infection (usually needs surgery and weeks/months of IV antibiotics)
 post-operative confusion, medication reaction, stroke, permanent disability.
 kidney or other organ failure, respiratory & cardiac arrest, death
Specific Serious Risks:
6. Bone or tissue grafts from human donors are likely to be used:
(no test will 100% detect Hepatitis and HIV (Human Immunodeficiency Virus) so
there is some small risk of disease transmission with the use of “Allograft”
7. Blood product transfusion with blood is needed in approximately
% of similar
cases (potentially life threatening allergic reactions, infection, kidney failure and
viral infections (Hepatitis & HIV) can follow blood or blood product administration)
8. If during my procedure, other conditions arise that need to be treated, Dr. Hatch will
perform any other necessary procedures and get any needed help/consultations.
9. I understand that no guarantees have been made to me by Dr. Hatch
Authorization for Procedures/Interventions and
Anesthesia Including Blood/Blood Products
jph 2014-7
CCD Informed Consent for Surgery – J. Hatch MD FRCSC
Coastal Carolina Hospital
CCD1AC CCD1186 Trial 09/13
1. I give my permission to Dr. Jeremy Hatch MD and his assistants:
to perform the following procedure(s)
on (patient’s name)
2. I understand that during the procedure(s) new findings or conditions may appear and require an additional procedure(s) for
proper care.
3. My doctor has discussed with me the items listed below:
(a) the nature of my condition;
(b) the nature and purpose of the procedure(s) that I am now authorizing;
(c) the possible complications and side effects that may result, problems which may be experienced during recuperation,
and the likelihood of success;
(d) the benefits to be reasonably expected from the procedure(s);
(e) the likely result of no treatment; and
(f) the available alternatives, including the risks and benefits.
(g) My physician has also explained that, in addition to the specific risks involved in the procedure(s), there are other
possible risks that accompany any surgical and diagnostic procedure. I understand these risks are not an exhaustive
list of every risk possible. I acknowledge that neither my physician nor anyone else involved in my care has made
any guarantees or assurances to me as to the result of the procedure(s) that I am now authorizing.
(h) I know other clinical staff may help my doctor during the procedure(s) and have been told of any surgical assistants
that will assist my doctor.
4. Any tissue or specimens taken from my body as a result of the procedure(s) may be examined and disposed of, retained,
preserved, or used for medical, scientific, or teaching purposes by the hospital.
5. I understand my procedure(s) may be photographed or videotaped and that observers may be present in the room for the
purpose of advancing medical care and education; and that my identify will not be revealed in said photos or video.
6. I understand that, during or after the procedure(s) my doctor may feel it necessary to give me a transfusion of blood or blood
products. My doctor has discussed with me the alternatives to, and possible risks of transfusion.
7. Additional comments:
I understand what my doctor has explained to me and I have had all my questions fully answered. Having
talked with my doctor and having the opportunity to read this form, my signature below acknowledges my
consent to the performance of the procedure(s) described above.
8. ANESTHESIA: I understand the procedure(s) may require that I undergo some form of anesthesia, which may have its own
risks. If a method other than local anesthesia or moderate sedation is to be utilized, an Anesthesiologist has informed me of
the course of anesthesia that is recommended along with its possible risks and alternatives.
Signature Anesthesiologist:______________________________________Date:______________Time:________________
Signature of Patient or Legal Representative
If Legal Representative, Relationship to Patient
Verbal or Telephone Consent:
Name of Legal Representative
Relationship to Patient
I have explained the risk, benefits, potential complications, and alternatives of the treatment to the Patient or Legal Representative and
have answered all questions to the patient’s satisfaction, and he/she has granted consent to proceed.
Signature of Physician
Authorization for Procedures/Interventions and
Anesthesia Including Blood/Blood Products
Time __________
jph 2014-7