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    Informed Consent Catheter Insertion

    Uploaded by

    Dedik Karyadi
    This informed consent document summarizes the medical treatment and risks for a 30-week pregnant patient diagnosed with intrauterine preeclampsia. The document outlines: 1) The diagnosis of intrauterine preeclampsia based on anamnesis, physical examination, blood and urine samples. 2) The medical treatment plan of inserting a urine catheter to monitor fluid output. 3) The risks of infection and discomfort from the procedure and the goal of monitoring fluids accurately. 4) Both the patient and doctor signatures to document the discussion and consent of the planned treatment.

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    Informed Consent Catheter Insertion

    Uploaded by

    Dedik Karyadi
    17 views2 pages
    This informed consent document summarizes the medical treatment and risks for a 30-week pregnant patient diagnosed with intrauterine preeclampsia. The document outlines: 1) The diagnosis of intrauterine preeclampsia based on anamnesis, physical examination, blood and urine samples. 2) The medical treatment plan of inserting a urine catheter to monitor fluid output. 3) The risks of infection and discomfort from the procedure and the goal of monitoring fluids accurately. 4) Both the patient and doctor signatures to document the discussion and consent of the planned treatment.

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    informed consent catheter insertion

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    This informed consent document summarizes the medical treatment and risks for a 30-week pregnant patient diagnosed with intrauterine preeclampsia. The document outlines: 1) The diagnosis of intrauterine preeclampsia based on anamnesis, physical examination, blood and urine samples. 2) The medical treatment plan of inserting a urine catheter to monitor fluid output. 3) The risks of infection and discomfort from the procedure and the goal of monitoring fluids accurately. 4) Both the patient and doctor signatures to document the discussion and consent of the planned treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    17 views2 pages

    Informed Consent Catheter Insertion

    Uploaded by

    Dedik Karyadi
    This informed consent document summarizes the medical treatment and risks for a 30-week pregnant patient diagnosed with intrauterine preeclampsia. The document outlines: 1) The diagnosis of intrauterine preeclampsia based on anamnesis, physical examination, blood and urine samples. 2) The medical treatment plan of inserting a urine catheter to monitor fluid output. 3) The risks of infection and discomfort from the procedure and the goal of monitoring fluids accurately. 4) Both the patient and doctor signatures to document the discussion and consent of the planned treatment.

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    Informed consent

    INFORMED CONSENT

    Performing doctor
    Information provider
    Information receiver
    1 Diagnosis (Working Diagnosis & G1P0A0 30 weeks
    Differential Diagnosis) intrauterine preeclampsia
    2 Reasons diagnosis Anamnesis, physical
    examination, blood sample,
    urine sample
    3 Medical treatment Insertion of urine catheter
    4 Indication Pro Sectio Caesarea
    5 Procedure according standar procedur
    6 Purpose to monitor fluids output
    7 Risk infection
    8 Complication unpleasant feeling
    9 Prognosis bonam
    10 Alternative and risk collecting urine manually,
    fluid monitoring not
    accurately performed

    hereby declare that I have explained the above matter correctly, doctor signature
    honestly and provided an opportunity to ask questions and/or discuss
    Hereby declare that I have received the information as above which I pasient/guardian
    marked in the right column, and have understood it signature
    Informed Consent document Name : mrs Sayur
    Date of birth : 01-01-2000
    Medical record number :202020

    Medical Action Approval


    I am who signed below,
    name mr. Sayur
    date of birth/age…02/02/2993…30yrs old….Male/Female
    address…karangsem……….
    I hereby express my consent to take medical action …………urine catheter insertion…………..
    on (date)……13/03/23……….. to me/to my…………wife………… named………mrs. Sayur………….., date
    of birth/age…01/01/2000…23yrs old….male/female, address………karangasem…………..
    I also realize that doctors will make efforts and because medical science is not an exact science,
    the success of medical procedures is not a necessity, but very much depends on the permission of
    the almighty God.

    ………Amlapura……….. date ………13/03/23………….. time ………10.00…….

    person who stated doctor witness 1 (family) witness 2 (staff)

    Refusal of Medical Action


    I am who signed below,
    name
    date of birth/age…….. Male/Female
    address………….
    I hereby express my refusal to take medical action ……………………..
    on (date)…………….. to me/to my…………………… named………………….., date of
    birth/age……….male/female, address…………………..
    I understand the need for and benefits of the medical action as explained above to me including
    the risks and complications that may arise if the medical action is not carried out.

    ……………….. date ………………….. time …………….

    person who stated doctor witness 1 (family) witness 2 (staff)

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