Professional Documents
Culture Documents
URN:
Family name:
Address:
A. Interpreter / cultural needs • Scarring may develop about the anus, and it may be
painful or thickened.
An Interpreter Service is required? Yes No
• Rarely the muscles at the anus may be over stretched or
If Yes, is a qualified Interpreter present? Yes No over cut with a resultant weakness in the area. This could
A Cultural Support Person is required? Yes No cause problems with control of the bowels (incontinence).
If Yes, is a Cultural Support Person present? Yes No A pad may need to be worn and/or further surgery may
be needed.
B. Condition and treatment • Increased risk in smokers of wound and chest infections,
heart and lung complications and thrombosis.
The doctor has explained that you have the following
condition: (Doctor to document in patient’s own words)
D. Significant risks and procedure options
.......................................................................................................................................................................... (Doctor to document in space provided. Continue in Medical
Record if necessary.)
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• Blood clot in the leg (DVT) causing pain and swelling. In ...........................................................................................................................................................................
rare cases part of the clot may break off and go to the
lungs. G. Patient consent
• Death as a result of this procedure is possible. I acknowledge that the doctor has explained;
Specific risks: • my medical condition and the proposed procedure,
• There will be an open wound where the fistula was including additional treatment if the doctor finds
removed. This will take 2-3 weeks to heal. something unexpected. I understand the risks, including
the risks that are specific to me.
• If the fistula involves an excessive amount of muscle
around the anus, the doctor may insert a small plastic • the anaesthetic required for this procedure. I understand
SW9088
marker to assist in drainage until further surgery is the risks, including the risks that are specific to me.
possible. • other relevant procedure/treatment options and their
• The condition may recur, and an abscess about the anal associated risks.
region may occur. • my prognosis and the risks of not having the procedure.
URN:
Family name:
Address:
I have been given the following Patient Information (state the patient’s language here) of the consent form
Sheet/s: and assisted in the provision of any verbal and written
Anaesthetic: Nerve Block OR information given to the patient/parent or
guardian/substitute decision-maker by the doctor.
Epidural & Spinal Anaesthetic
Name of
Fistula in Ano Interpreter: ....................................................................................................................................
Signature:.......................................................................................................................................
On the basis of the above statements,
I request to have the procedure Date:.....................................................................................................................................................
V5.00 – 12/2018
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Permission to reproduce should be sought from ip_officer@health.qld.gov.au
Consent Information - Patient Copy
© The State of Queensland (Queensland Health), 2018
Fistula in Ano
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stretched or over cut with a resultant weakness in
the area. This could cause problems with control ...........................................................................................................................................................................
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