20 10 model medical informed consent form
Editor-in-Chief of Medical Compilation: Susan Wang; Editor-in-Chief: He Quanying, Gao Zhancheng, Wang Jun, Hu Dayi, Tang Chuzhong, Zhang Xiaoming, Wei Lai, Ji Linong and Li (in chapter order). Gao Xiao Feng Wei Wang Jian Liu Lv Hou Shan Guo Liu Haiying Gui Lan Wang Shaojie Zhang Jianzhong Yang Baxian Yi Feng An Youzhong Leng Xisheng Zhu Jiye Ye Yingjiang Huang Xun Yang Deqi Li Xiaoxin Yu Lisheng Gao Chengzhi Feng Guoping Du Xiangke Wu Shaopeng Wang Qian Tian Wenqin Shen Danhua Editor-in-Chief: Cui Zhende Editor-in-Chief: Zhao Hongmei Deng Mang Sun Wei Fu Yao Directory First Publicity Part1,Admission Notice 6 5 438+0 2. Power of attorney 54, notice of critical illness 65, informed consent of blood transfusion/blood products treatment 8 6, notice of using self-funded drugs and medical consumables 10 7, notice of refusing or giving up medical treatment18, notice of automatic discharge or transfer 13 9. Notice to discourage inpatients from going out 15 10. Autopsy Notice 16 Part II Clinical Branch 17 Chapter I Respiratory System 17 Section I General Informed Consent of Respiratory System 17 Informed Consent of Chemotherapy for Lung Cancer 17 Section II Respiratory Department 19 1 CT/B 9 2, informed consent of anti-tuberculosis treatment 2654 informed consent of mediastinoscopy operation 27 3, informed consent of thoracoscopic pulmonary wedge resection or bullae resection 29 4, informed consent of thoracoscopic pulmonary resection or thoracotomy 3 1 5, informed consent of esophagectomy 34 6, informed consent of palmar hyperhidrosis, long QT syndrome 37 7, informed consent of rigid bronchoscopy operation 40 8, Informed Consent of Closed Thoracic Drainage 43 Chapter II Circulation System 45 Section 1 Cardiology Department 45 1, Informed Consent of Cardiac Electrophysiological Interventional Diagnosis and Treatment 45 2, Informed Consent of Cardiac Catheter Diagnosis and Treatment 48 3, Informed Consent of Pericardial Puncture Examination and Treatment 50 Section 2 Cardiology Department 52 1, Informed Consent of Valvular Heart Surgery 52 2 2, Informed Consent of Coronary Artery Bypass Grafting 55 3, Informed consent for congenital heart disease surgery 58 4, informed consent for pericardial disease surgery 6 1 5, informed consent for cardiac foreign body exploration 63 6, informed consent for cardiac tumor surgery 13, informed consent for superior mesenteric artery incision and/or endarterectomy 67 2, high ligation and stripping of great saphenous vein 69 3, laser treatment of great saphenous vein 7 1 4, Abdominal aortic aneurysm resection, abdominal aorta-bilateral iliac or femoral artery bypass transplantation, brachial artery/femoral artery/popliteal artery incision and exploration, embolectomy. Informed consent of femoral artery-femoral artery artificial blood vessel or autologous great saphenous vein bypass operation 77 7, femoral artery-popliteal artery artificial blood vessel or autologous great saphenous vein bypass operation 79 8, lower limb amputation operation 8 1 9, carotid artery incision exploration 83 1, portal vein-vena cava or superior mesenteric vein-vena cava or splenic vein-renal vein shunt operation/ Informed Consent of Artificial Vascular Bypass Surgery 85 1655 Informed Consent of Arteriovenous Fistula of Upper Limbs (or Artificial Vascular Fistula) 91KLOC-0/4, Informed Consent of Artificial Vascular Replacement of Ascending Aorta, Aortic Arch, Descending Aorta, Partial Branch Reconstruction of Arch, Coronary Artery Reconstruction and Aortic Valve Replacement (Under Extracorporeal Circulation) 93/KLOC Informed consent form 96 16 for Budd-Chiari syndrome radical operation assisted by cardiopulmonary bypass, informed consent form 98 16 for visceral artery reconstruction 100 18, laser or sclerotherapy for hemangioma (venous malformation)/kloc-0. Hemangioma (venous malformation) resection 104 20, informed consent of axillary-axillary artery bypass surgery 106 Chapter III Digestive System 108 Section I Gastroenterology 108 1, informed consent of gastroscope dilatation/kloc-0. Endoscopic polypectomy /EMR/ESD informed consent 120 8, ERCP informed consent 122 9, informed consent for endoscopic stent implantation 125 Section II Hepatology Department 127 1, informed consent for ascites reinfusion/kloc- Kloc-0/29 3, informed consent of percutaneous radiofrequency ablation of liver tumor 65433, informed consent of donors for bone marrow collection 135 3, informed consent of donors for apheresis of blood cell separator 137 4, informed consent of donors for frozen stem cell/lymphocyte infusion 139 5, informed consent of donors for receiving bone marrow and/ Or the informed consent form (HSCT) 14 1 6, the informed consent form for in vitro collection and cryopreservation 143 7, the informed consent form for receiving autologous joint cavity puncture 150 2, and the informed consent form for pulse therapy with prednisolone A 152 3. Kloc-0/54 4, Informed Consent for Immunosuppressant Treatment 156 5, Informed Consent for Biological Agents Treatment 158 6, Informed Consent for Tissue Biopsy 160 Chapter VII Nervous System 162 Section 1 Neurology 166 Informed Consent for Intravenous Thrombolysis of Acute Cerebral Infarction. Informed consent of cerebral angiography (DSA) 168 5, craniotomy 170, neurosurgery 172 1, aneurysm clipping 172 2 2, craniotomy and intracranial tumor resection/. Chapter VIII Urinary and Male Reproductive System 174 Informed Consent for Continuous Renal Replacement Therapy 180 4, Informed Consent for Renal Biopsy 182 5, Informed Consent for Immunosuppressant Therapy 184 6, Informed Consent for Plasma Exchange 186 7, Informed Consent for Hemodialysis/. 88 urology in the second quarter 190 1, informed consent of partial cystectomy 190 2, informed consent of cystoscopy 6544 informed consent of cystostomy 200 7, informed consent of circumcision 202 8, informed consent of suprapubic cystotomy 206 10, Informed Consent of Laparoscopic Radical Ureteral Carcinoma 208 1 1, Laparoscopic Radical Prostate Cancer 21kloc-0/2, Laparoscopic Partial Nephrectomy 2 12, Radical Testicular Excision 2 16 15. Kloc-0/8 16, informed consent of kidney harvesting in vivo 220 17, informed consent of transurethral cystotomy 222 18, informed consent of transurethral resection of bladder tumor 224 19, informed consent of transurethral resection of prostate 222 high ligation of spermatic vein (222) Informed consent of high ligation of spermatic vein 234 24, informed consent of intravenous pyelography 236 25, informed consent of laparoscopic radical prostatectomy 238 26, informed consent of radical nephrectomy 240 27, informed consent of nephrostomy 242 28, informed consent of renal cyst fenestration 244 29, informed consent of retrograde pyelography 246 30, Informed Consent of Bilateral Testicular Excision 248 365438+ Informed Consent of Radical Penile Cancer 252 33, Informed Consent of Partial Penile Excision 254 Chapter 9 Female Reproductive System 256 Section 1 Gynecology 256 1, Informed Consent of Gynecological Examination/Treatment 256 2, Informed Consent of Gynecological Surgery 258 3, Informed Consent of Ectopic Pregnancy Diagnosis and Treatment 260 4, Informed Consent of Cervical Biopsy 263 5, Informed Consent of Diagnostic Curettage and Segmented Curettage 265 6, Informed Consent of Gynecological Tumor Chemotherapy 267 Section 2 Obstetrics 2765438+ Cesarean Section 27 1 2, Informed Consent of Umbilical Vein Puncture 273 3, Informed Consent of Chorionic Sampling 275 4, Informed Consent of Prenatal Blood Biochemical Screening 277 5, Informed consent for newborn hearing screening 278 6, informed consent for amniocentesis 279 7, informed consent for vaginal delivery 28 1 Section III Family Planning Department 284 1, informed consent for operation of placing intrauterine device (IUD) 284 2, informed consent for hysteroscopy operation and informed consent for taking out intrauterine device 288 4, negative pressure suction for induced abortion/ Informed consent of curettage operation 290 5, informed consent of drug abortion 292 6, informed consent of induced labor operation in the second trimester 294 Chapter 10 Bone system 296 Section 1 Traumatic Orthopedics 296 1, informed consent of proximal humeral fracture operation (including internal fixation and shoulder replacement) 296 2, informed consent of open reduction and internal fixation of humeral shaft fracture 298 3, Informed consent of distal humeral fracture surgery (including internal fixation and elbow replacement) 300 4, informed consent of open reduction and internal fixation of distal radius fracture 302 5, informed consent of intertrochanteric fracture surgery 304 6, informed consent of hollow nail internal fixation of femoral neck fracture 306 7, informed consent of femoral shaft fracture surgery 308 8, informed consent of open reduction and internal fixation of tibial plateau fracture 3 1/ Kloc-0/ 9, informed consent of open reduction and internal fixation of ankle fracture 3 14 10, informed consent of percutaneous kyphoplasty of spinal compression fracture 3 17 1 1, informed consent of internal fixation removal 3 19. Informed consent form for revision of artificial hip joint 327 5, total knee replacement 329 6, total knee replacement revision 33 1 Section III Bone Oncology Department 333 1, pelvic tumor resection and artificial prosthesis reconstruction 333 2, sacral tumor resection and internal fixation 335 3, Informed consent of spinal tumor resection and internal fixation surgery 337 4, informed consent of limb tumor resection and reconstruction surgery 339 5, informed consent of central venous catheterization and chemotherapy 34 1 Section IV informed consent of spinal surgery 343 1 myelography 343 2, informed consent of spinal orthopedic surgery 345 3, informed consent of anterior cervical surgery 348 4, Informed Consent of Posterior Cervical Surgery 35 1 5, Informed Consent of Posterior Thoracic Surgery 354 6 6, Informed Consent of Posterior Lumbar Surgery 356 7, Informed Consent of Percutaneous Vertebroplasty 359 Chapter XI Pediatrics 36 166 Informed Consent of Premature Infants' Condition and Treatment 363 Chapter XII Chinese Medicine 365 1, Informed Consent of Needle-Knife Closure Operation 365 Chapter XIII Dermatology 367 1, Skin Patch Test 367 2, Carbon Dioxide Laser Treatment 369 3, Ultraviolet Treatment 37 1 4, Cryopreservation/Microwave Treatment 373 5, Skin Tumor Excision/Biopsy 375 6, Informed consent for laser hair removal and laser cosmetic treatment 379 Chapter XIV Anesthesiology Department 38 1 1 Anesthesia Informed Consent 38 1 2, Anesthesia/Assisted Sedation Informed Consent 384 Chapter XV ICU 386 1, Inpatient ICU Informed Consent 386 2, Blood Purification Informed Consent 388 3, Informed consent of central venous catheterization and hemodynamic monitoring 39 1 4, informed consent of ICU patients using disposable articles 386 informed consent of bile duct exploration operation 399 4, informed consent of bile duct system operation 402 5, informed consent of retroperitoneal tumor operation 405 6, informed consent of partial hepatectomy 407 7, informed consent of liver operation 4 1/ Kloc-0/ 8, informed consent for liver transplantation 4 15 9, informed consent for portal hypertension 4 18 10, informed consent for hernia surgery 420 165438, informed consent for pancreatic cancer surgery 43 16, informed consent for spleen surgery 434. Kloc-0/8, breast surgery 439 Chapter 17 Ophthalmology 44 1 1, Retinal detachment reduction surgery (premature delivery) 44 1 2, cataract intraocular lens surgery 4333, informed consent of vitrectomy for vitreous macular traction syndrome 454, Informed Consent of Vitrectomy for Retinal Vascular Disease with Vitreous Hemorrhage 453 8, Informed Consent of Corneal Surgery 455 9, Informed Consent of Conjunctival Surgery 457 10, Informed Consent of Lacrimal Surgery 4591,Informed Consent of Intraocular Tumor Applicator Brachytherapy 46 1 2. Informed consent for glaucoma surgery 463 13, informed consent for retinal detachment reduction 465 14, eye trauma suture 467 65438+ excimer laser corneal refractive surgery 477 20, excimer laser therapeutic keratectomy 479 2 1, transpupillary thermotherapy (TTT) 48/kloc. Informed consent of vitreous cavity injection (Avastin) surgery 484 23, fundus fluorescein angiography 486 24, laser treatment of retinal holes 488 25, laser treatment of retinal vascular diseases 490 26, informed consent of PDT patients 492 27, informed consent of indocyanine green angiography 494 28 informed consent of endoscopic nasal electrocoagulation hemostasis 498 2, Informed consent for resection of malignant tumor of nasal cavity and paranasal sinuses 500 3, informed consent for resection of benign tumor of nasal cavity and paranasal sinuses 502 4, informed consent for resection of inverted papilloma of nasal cavity and paranasal sinuses 504 5, dacryocystostomy 506 6, resection of nasopharyngeal fibroangioma 508 7, correction of nasal septum deviation 5 10 8, tonsillectomy 5 12 9, Informed consent of cochlear implant 566 informed consent of uvulopalatoplasty 5161,informed consent of radical laryngectomy/hypopharyngeal cancer combined operation 5 18 12, informed consent of laser surgery under laryngoscope 520 65438. Informed consent for neck tumor resection 522 14, chronic sinusitis and nasal polyps surgery 524 15, fungal sinusitis and paranasal sinus surgery 526 16, vocal cord polyp or lesion resection 528 17, and extranasal tumor resection 530/kloc-. Informed consent of adenoidectomy 532 19, informed consent of chronic suppurative otitis media surgery 538 3, informed consent of orthodontic surgery 540 4, informed consent of dental treatment 542 5, informed consent of dental implant restoration treatment 544 Chapter 20 Medical Beauty Department 546 1, informed consent of medical beauty department surgery 546 2, Informed consent for blepharoplasty 548 3, rhinoplasty 504, chin augmentation 552 5, inner canthus surgery 546, minimally invasive bromhidrosis surgery 556 7, liposuction surgery 558 8, tumor resection surgery 560 9, double eyelid surgery 562 Chapter 21 Radiology Department 564/kloc. Informed consent of pyelography 57 1 chapter 22 informed consent of radiotherapy department 573 1 informed consent of radiotherapy department 573 chapter 23 informed consent of nuclear medicine department 575 1 31informed consent of iodine radionuclide treatment 575 2, Informed Consent of Radionuclide Therapy for Bone Metastasis and Bone Pain Chapter 24 General informed consent of all subjects 579 1, informed consent of thoracic puncture 5 informed consent of lumbar puncture and intrathecal injection 585 5, informed consent of bone marrow puncture/biopsy 587 6, informed consent of liver puncture 589 7, () informed consent of operation 59 1 8, Informed consent of intraoperative frozen section examination 593 9, informed consent of peripherally inserted central venous catheter (PICC) operation 594 10, informed consent of deep venous catheterization 596 1 1, informed consent of tracheal intubation and mechanical ventilation 598.