Informed Consent Documentation

• Proposed treatment: Wide local excision of a 6 mm pigmented skin lesion on the R forearm under local anaesthetic (lidocaine 1% 5 mL SC stat) for suspected superficial spreading melanoma.

• Risks and benefits: Benefits: Histopathological diagnosis and definitive local clearance. Risks: Bleeding, surgical site infection, wound dehiscence, hypertrophic/keloid scarring, paraesthesia, incomplete excision requiring re-excision, and rare allergic reaction to local anaesthetic.

• Response: Patient understands the rationale and accepts the procedural risks; expressed minor concern regarding cosmetic appearance of the scar.

  • Patient asked about post-op activity restrictions and suture removal; advised to avoid heavy lifting for 14 days and return in 10 days for ROS.

• Alternative options: Punch biopsy (risk of sampling error), referral to plastic surgery (increased cost and wait time), or no treatment (risk of local invasion, metastasis, and death).

• Resources provided: Printed handout, "Excision of Skin Lesions", https://www.melanoma.org.au/excision-guide, Melanoma Institute Australia, v3.2.

• Consent process: Written consent obtained with patient signature on clinic surgical consent form.

  • 24/05/2024 at 14:15 AEST
  • Dr Sarah Jenkins, MBBS FRACGP, [Signed: S. Jenkins]
  • Performed by Dr Sarah Jenkins (same as consenting clinician).

Additional

• Patient previously deferred excision on 10/05/2024 due to work commitments; today explicitly revoked earlier deferral and requested to proceed.
• Patient declined viewing clinical photographs of post-operative scarring, stating they understood the verbal description sufficiently.
• Competency assessed via teach-back method; patient accurately paraphrased the procedure, indications, and key risks.
• Mild presbycusis noted; managed by speaking clearly in a quiet consultation room and providing written materials. No substitute decision-maker required.