Morrison_A_Assignment 6
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School
East Carolina University *
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Course
3030
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
4
Uploaded by asmorrison330
Consent for Treatment:
Intravenous Pyelogram
Patient Name:
Patient Date of Birth:
I,
approve and consent Dr. (s)
to perform an
intravenous Pyelogram.
Sedation and Anesthesia
With anesthesia (pain medication that will allow you to fall asleep without feeling pain)
With mild sedation (pain medication that will allow you to feel drowsy and fall asleep)
No sedation
I understand the risks, benefits, and different alternatives when it comes to sedation and
anesthesia. All of my questions and concerns have been answered by the anesthesiologist and
radiologist who is performing the Intravenous Pyelogram.
I agree to the Intravenous Pyelogram procedure, so my kidneys, ureters, and bladder can be
thoroughly evaluated and agree for other procedures to take place during this procedure if the
radiologist finds an unexpected obstruction(s) to reduce the risk of future complications
reoccurring.
Risks
I understand that overall, this is a safe procedure with the risks of this procedure being very low.
There is a 1 in a 100,000 chance of death occurring with Intravenous Pyelogram.
Side effects
I understand that there are potential side effects that could happen with the dye when undergoing
Intravenous Pyelogram, such as:
a mild reaction like hives
severe reaction like difficulty breathing
possibility of swelling
produce a warm feeling
Benefits
I understand that Intravenous Pyelogram will help determine if there is an obstruction in the
urinary tract and evaluate if there are any other issues. It’ll also help the radiologist determine the
cause and treat the abnormalities to prevent them from happening again.
Alternative procedures
I understand that the radiologist determines the best procedure given my condition.
If other
procedures are considered instead of the Intravenous Pyelogram these options would be:
Full body CT scan
MRI
Possibly surgery depending on the findings
The CT and MRI can evaluate the kidney, ureters, and bladder. However, given the
circumstances of the possibility of an obstruction in the urinary tract, an intravenous pyelogram
would be better suited with less complications and risk. I understand that if I decide to not
receive treatment there is a possibility of deterioration and severe health issues.
Alternative Risks
I understand that there are general risks associated with any invasive procedure such as:
Possibility of infection
Nausea
Death
Exposure to radiation
Vomiting
Consent to take part in medical research, study, or education related to my care
I,
consent to have picture taken for medical research, study, or educational
purposes related to my care. I agree for pictures to be taken followed by HIPAA regulations. As
well as agree to have observers and health representatives in the intravenous pyelogram room.
Interpreter and Translation Services Statement
I understand that if English is not my first language, I have the right to an interpreter and or
translation services during the informed consent process and before and after the procedure.
Would an interpreter be needed?
o
Yes
o
No
Signatures
My signatures below mean that:
I thoroughly read and understand the terms of this consent form.
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All of my questions and concerns have been answered.
All information pertaining to before and after care of the procedure have been explained.
I consent to everything explained in this document.
Patient’s signature
:
Date singed
:
Radiologist signature
:
Date signed
:
Anesthesiologist signature
:
Date signed
:
Witness
:
Date signed
:
If the patient is unable to consent themselves, the guardian may complete the following:
Patient
is unable to consent due to
.
Legally responsible person:
Relationship to patient:
Date signed:
If an interpreter was used:
Signature of interpreter:
Date of Service: