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Beneficence and Nonmaleficence Neurosurgeon and Spine Surgeon Carpal Tunnel Release A. Interpreter / cultural needs
• Redness and peeling of the palm. This usually
Uncommon risksand complications include:
If yes, is a qualified Interpreter present?
• Bleeding can occur and may require a return to
the operating room. Bleeding is more common if
you have been taking blood thinning drugs such
If yes, is a Cultural Support Person present? Yes No
as Warfarin, Asprin, Clopidogrel (Plavix or
B. Condition and treatment
The doctor has explained that you have the following
• Numbness and tingling in the fingers and thumb
condition: (Doctor to document in patient’s own
• The operation occasionally does not work and
• Damage to the tendons, which may require
• Damage to the median nerve, requiring re-
This condition requires the following procedure.
(Doctor to document - include site and/or side where
• Wrist pain when making a fist or leaning on the
• The surgical cut may cause changes to the
• In some people, healing of the wound can
become thickened and red and the scar may be
Rare risksand complications include:
• Increased risk in obese people of wound
infection, chest infection, heart and lung
• Severe burning pain, unresponsive to treatment. co
• Death as a result of this procedure is very rare.
D. Significant risks and procedure (Doctor to document in space provided. Continue in
A Carpal Tunnel release is a procedure to free the
median nerve which runs through the carpal tunnel in
E. Risks of not having this procedure (Doctor to document in space provided. Continue in C. Risks of this procedure
There are risks and complications with this procedure.
They include but are not limited to the following.
Common risksand complications include:
• Infection, requiring antibiotics and further
• Minor pain, bruising and/or infection from IV
cannula site. This may require treatment with
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Beneficence and Nonmaleficence Neurosurgeon and Spine Surgeon Carpal Tunnel Release F. Anaesthetic
This procedure may require an anaesthetic. (Doctor I request to have the procedure to document type of anaesthetic discussed)Name of Patient/ Substitute decision maker and relationship:. Signature:. Date:.…………………………………………………… ……. Substitute Decision-Maker: Under the Powers of Attorney Act G. Patient consent 1998 and/or the Guardianship and Administration Act 2000. If the
patient is an adult and unable to give consent, an authorised
I acknowledge that the doctor has explained;
decision-maker must give consent on the patient’s behalf.
• my medical condition and the proposed
procedure, including additional treatment if the
H. Doctor’s statement
doctor finds something unexpected. I understand
the risks, including the risks that are specific to
I have explained to the patient all the above points
under the Patient Consent section (G) and I am of
the opinion that the patient/substitute decision-
• the anaesthetic required for this procedure. I
understand the risks, including the risks that are
Doctor:.
• other relevant procedure options and their
Designation:.
• my prognosis and the risks of not having the
Signature:.
• that no guarantee has been made that the
.…………………………………………………………….
procedure will improve my condition even though
Anaesthetist:
it has been carried out with due professional
Designation:.
• the procedure may include a blood transfusion.
Signature:.
• tissues and blood may be removed and could be
Date:.…………………………………………………………….
condition, stored and disposed of sensitively by
I. Interpreter’s statement
• if immediate life-threatening events happen
during the procedure, they will be treated
• a doctor other than the Specialist Neurosurgeon
(state the patient’s language here) of the consent
may conduct the procedure. I understand this
form and assisted in the provision of any verbal and
could be a doctor undergoing further training.
written information given to the patient/parent or
I have been given the following Patient
guardian/substitute decision-maker by the doctor.
Information Sheet/s; Interpreter: Local Anaesthetic for Your Procedure Carpal Tunnel Release Signature: .
• I was able to ask questions and raise concerns
Date:.…………………………………………………………….
with the doctor about my condition, the proposed
procedure and its risks, and my treatment
options. My questions and concerns have been
discussed and answered to my satisfaction.
• I understand I have the right to change my mind
at any time before the procedure, including after I
have signed this form but, preferably following a
Consent Information - Patient Copy Carpal Tunnel Release Beneficence and Nonmaleficence Neurosurgeon and Spine Surgeon 1. What is a Carpal Tunnel Release?
• Damage to the tendons, which may require
A Carpal Tunnel release is a procedure to free the
median nerve which runs through the carpal tunnel in
• Damage to the median nerve, requiring re-
It involves making a small cut down the front of the
• Wrist pain when making a fist or leaning on the
wrist and palm of the hand and dividing the band of
tissue which is pressing on the median nerve.
• The surgical cut may cause changes to the
Once the nerve is completely free, the skin is closed
• In some people, healing of the wound can
become thickened and red and the scar may be
Rare risksand complications include:
• Increased risk in obese people of wound infection,
chest infection, heart and lung complications and
• Severe burning pain, unresponsive to treatment. • Death as a result of this procedure is very rare.
Notes to talk to my doctor about
Medical illustration Copyright Nucleus Medical Art. Al Rights Reserved.
2. My anaesthetic
This procedure will require a Local Anaesthetic.
See Local Anaesthetic for Your Procedure patient
information sheet for information about the anaesthetic
and the risks involved. If you have any concerns, talk
these over with your doctor. If you have not been given an information sheet, 3. What are the risks of this specific procedure?
There are risks and complications with this procedure.
They include but are not limited to the following.
Common risksand complications include:
• Infection, requiring antibiotics and further
• Minor pain, bruising and/or infection from IV
cannula site. This may require treatment with
• Redness and peeling of the palm. This usually
Uncommon risksand complications include:
• Bleeding can occur and may require a return to
the operating room. Bleeding is more common if
you have been taking blood thinning drugs such
as Warfarin, Asprin, Clopidogrel (Plavix or
Iscover) or Dipyridamole (Persantin or Asasantin).
• Numbness and tingling in the fingers and the
• The operation occasionally does not work and
PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION PATIENT REGISTRATION IF YOUR CHILD S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE TOP BOX ALSOPERSON FINANCIALLY RESPONSIBLE FOR ACCOUNTRELATIONSHIP TO PATIENT SOCIAL SECURITY NO. IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE? YOU WERE REFERRED TO US BY YOUR FORMER ADDRESS PERSON TO
Milk Thistle Text by Armando González Stuart, Ph.D., 2005 Botanical family: Asteraceae (Compositae). Other common names: Marian thistle, St. Mary’s Thistle. Common names in Spanish: Cardo mariano, Cardo lechoso. Medicinal parts: The dried, ripe fruits or achenes (“seeds”). The ripe fruits or achenes (“seeds”) of this plant have been employed in Europe for many
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Beneficence and Nonmaleficence
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Beneficence and Nonmaleficence
Consent Information - Patient Copy