(Affix identification label here) URN: Family name: Arthrogram Given name(s): Address: Date of birth: Sex: M F I Facility: ght from [email protected] ght from A. Interpreter / cultural needs An allergy to injected drugs, requiring further treatment. An Interpreter Service is required? Yes No The procedure may not be possible due to If Yes, is a qualified Interpreter present? Yes No medical and/or technical reasons. A Cultural Support Person is required? Yes No © The State of Queensland (Queensland Health), 2011 (Queensland Queensland of © The State Rare risks and complications include: If Yes, is a Cultural Support Person present? Yes No An increased lifetime cancer risk due to the exposure to x-rays (for CT and x-ray only). B. Procedure Seizures and/or cardiac arrest due to local The following will be performed (Doctor to document - anaesthetic toxicity. include site and/or side where relevant to the Permission to reproduce should be sou be should reproduce to Permission Death as a result of this procedure is very rare. procedure) ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... An Arthrogram is a procedure that injects Contrast into a joint. The Contrast injection is done with ........................................................................................................................................................................... guidance from imaging machines such as ultrasound, ........................................................................................................................................................................... or x-ray. After the injection of Contrast, further pictures are then ........................................................................................................................................................................... taken with CT, MRI or x-ray. ........................................................................................................................................................................... This procedure may require the use of a local PROCEDURAL CONSENT FORM anaesthetic. ........................................................................................................................................................................... C. Risks of an arthrogram ........................................................................................................................................................................... In recommending an Arthrogram, the doctor believes ........................................................................................................................................................................... the benefits to you from having this procedure exceed ........................................................................................................................................................................... DO NOT WRITE IN THIS BINDING MARGIN IN THIS BINDING DO NOT WRITE the risks involved. The risks and complications with this procedure can ........................................................................................................................................................................... include but are not limited to the following. Common risks and complications include: ........................................................................................................................................................................... Bleeding or bruising may occur. This is more ........................................................................................................................................................................... common if you take Aspirin, Warfarin, Clopidogrel (Plavix and Iscover) or Dipyridamole (Persantin ........................................................................................................................................................................... and Asasantin). ........................................................................................................................................................................... Failure of local anaesthetic which may require a further injection of anaesthetic or a different ........................................................................................................................................................................... method of anaesthesia may be used. ........................................................................................................................................................................... Nerve damage, is usually temporary, and should get better over a period of time. Permanent nerve ........................................................................................................................................................................... damage is rare. ........................................................................................................................................................................... Less common risks and complications include: v6.00 - 03/2011 ........................................................................................................................................................................... Infection, requiring antibiotics and further treatment. ........................................................................................................................................................................... Damage to surrounding structures such as blood vessels, organs and muscles, requiring further ........................................................................................................................................................................... treatment. ........................................................................................................................................................................... Inflammation of the joint, resulting in an increase SW9235 of fluid in and around the joint. Page 1 of 2 Continues over page ►►► (Affix identification label here) URN: Family name: Arthrogram Given name(s): Address: Date of birth: Sex: M F I Facility: D. Patient consent I request to have the procedure I acknowledge that the doctor/doctor delegate has Name of Patient:.......................................................................................................................... explained the proposed procedure. Signature: .......................................................................................................................................... I understand; Date: ...................................................................................................................................................... the risks and complications, including the risks Patients who lack capacity to provide consent that are specific to me. Consent must be obtained from a substitute decision the sedation/anaesthetic required for this maker/s in the order below. procedure. I understand the risks, including the Does the patient have an Advance Health Directive risks that are specific to me. (AHD)? if immediate life-threatening events happen Yes Location of the original or certified copy of the AHD: during the procedure, they will be treated based on my discussions with the doctor/doctor delegate ................................................................................................................................................................ or my Acute Resuscitation Plan. No Name of Substitute a doctor/doctor delegate undergoing further Decision Maker/s: ............................................................................................................... training may conduct this procedure. MARGIN IN THIS BINDING DO NOT WRITE Signature: ..................................................................................................................................... I have been given the following Patient Information Sheet/s: Relationship to patient:................................................................................................. Arthrogram Date: ....................................................... PH No:.................................................................. Ultrasound & OR Source of decision