DOI: 10.1093/bjs/znad258.145 ISSN:

804 Audit of Hand-Written Consent Form Documentation for Skin Lesion Excisions in the Plastic Surgery Procedure Room

O Egbuji, H Zengin, M Saad, A Rosich-Medina, N Sheppard
  • Surgery



To audit the hand-written consent forms for elective excision of skin lesions in the Procedure Room.


The notes and consent forms from 11 Procedure Room sessions were analysed. The total number of notes reviewed were 24. Our audit standards focused on the consenter and the completion of sections of the audit form. There are no standard guidelines for the complications of skin lesion excision, therefore a consensus from the general consultant body was used.


Our patient demographic mostly consisted of male patients (15, 63%) with a mean age of 50 (range 17 – 75). 83% of the procedures required no reconstruction, 8% were biopsies and 8% required a full thickness skin graft (FTSG). 75% of the consenting clinicians were Registrars. The rest were Senior House Officers. All the consenters documented their job title, signed and dated their signature. All were trained in consenting and each consenter performed the procedure. 100% of clinicians used the correct consent form, documented the proposed procedure, clearly documented the site and risks and placed a label on every page. 83% completed the ‘intended benefits’ section. 58% wrote the procedure name in full. Every clinician documented bleeding and infection as a risk factor. 54% pain, 75% re-excision of margins, 71% recurrence and wound breakdown, 96% scarring, 46% injury to surrounding structures and 0% anaesthetic risk. All patients who received a FTSG, had graft loss documented as a risk.


The quality of hand-written consent forms is user dependent. A pre-filled consent form is proposed to increase compliance.

More from our Archive