An audit of informed consent in gastroscopy: investigation of a hospital's informed consent procedure in endoscopy by assessing current practice.

Objective: To investigate, by assessing current practice, whether a UK general hospital's informed consent procedure in endoscopy was implemented for all patients, because informed consent is central to the proper conduct of endoscopic procedures.

Methods: A retrospective study of patients' medical notes, in which information written on the UK National Health Service (NHS) consent form and on a departmental leaflet on the gastroscopy procedure completed by the patient was assessed. Sampling began from 9 October 2003 until 100 patients were recorded. For each patient's record, a data collection sheet was completed.

Results: Of the 67 patient records assessed (33 were unavailable), all contained the NHS consent form with signatures from the practitioner and patient. The departmental leaflet was present for only 31 patients, and of these, 20 had a signature from the patient and one leaflet had a signature from the practitioner. The multiple choice test was completed for 28 of the 31 departmental leaflets and full marks were awarded for 17 of 28. Although 11 patients answered one or more questions incorrectly, a discussion of the correct answers was only found in two records.

Conclusion: To achieve improved performance, a training/induction programme should explain the informed consent procedure and its importance. This should be supported by 'booster' training sessions to avoid the emergence of bad practice. These sessions should take advantage of evidence-based medicine via feedback from audits and discussions of litigation cases. Departmental leaflets and NHS consent forms should also be provided in other languages.