Surgical Consent Discussion Note (Pediatrics)

Date/Time of Discussion: [Date and time of consent discussion]
Location: [Clinical setting]
Patient: [Patient full name and age]
Proposed Procedure: [Plain-language procedure name with laterality/site and approach; formal surgical name]
Primary Indication/Diagnosis: [Primary clinical indication or diagnosis prompting procedure]

(This note documents the informed consent conversation supporting shared decision-making and complements the facility's signed procedural consent form.)

Participants and Consent Authority

Participants: [Names and roles of parent(s)/guardian(s); whether the patient was present and their level of participation; interpreter used (language and in-person/remote); other relevant participants]
Consent Authority: [Name and relationship of individual(s) providing legal consent/permission and basis for authority (e.g., parent, legal guardian, court order)]
Communication Accommodations: [Language, interpreter mode, and any accommodations for developmental, cognitive, or sensory needs] (Omit if none required.)

(If custody or guardianship is uncertain, explicitly state that consent is pending verification and note the plan.)

Clinical Context

[Brief explanation (2–4 sentences) of the diagnosis/indication, key supporting findings, rationale for recommending surgery at this time, and anticipated consequences of no treatment or delay if relevant.] (Reference other clinical notes for detailed history rather than duplicating.)

Proposed Procedure

Procedure Description: [Plain-language description of what the procedure does, formal surgical name, and primary goal/definition of success]
Anesthesia: [Expected anesthesia type] (Note if anesthesia consent is handled separately.)
Surgeon: [Attending surgeon/proceduralist performing the procedure]
Foreseeable Contingencies: [Specific possible changes such as conversion of approach, additional procedures based on intraoperative findings] (Be specific; avoid blanket "anything necessary" language.)

Alternatives

• [Alternative 1]: [Key benefits and drawbacks]
• [Alternative 2]: [Key benefits and drawbacks]
• No intervention: [Expected course without intervention]

(Include only reasonable alternatives that were actually discussed.)

Risks and Expected Benefits

(Document only material risks that were actually discussed. Name specific structures at risk when relevant.)

• Common/Expected Effects: [Post-op pain, swelling, bruising, temporary functional limits, expected recovery course]
• Serious but Less Common Risks: [Bleeding, infection, damage to specific structures, need for reoperation, anesthesia risks, other procedure-specific risks as discussed]
• Patient-Specific Risk Modifiers: [Age-related factors, comorbidities, prior surgeries, anatomical considerations] (Omit if none.)
• Expected Benefits: [Primary goals, realistic expectations, anticipated time horizon for improvement]

(If a standard institutional risk list was reviewed verbally, note this and specify which material risks were emphasized.)

Pediatric Assent

Patient Involvement: [What was explained in age-appropriate terms; how understanding was assessed; expressed willingness or concerns]
Assent Status: [obtained / patient willing to proceed / concerns noted / not feasible—state reason]

(If assent not feasible due to young age, developmental status, or clinical acuity, document the reason and note supportive preparation provided.)

Questions, Understanding, and Decision

Questions/Concerns: [Questions or concerns raised by caregiver/patient and answers provided] (If none: "Questions invited; none at this time.")
Evidence of Understanding: [Teach-back or other evidence that caregiver/patient can restate plan, main risks, and alternatives]
Values/Preferences: [Goals, cultural or religious considerations, recovery priorities influencing decision] (Omit if none specific.)
Decision: [proceeding / deferring / declining / seeking second opinion]

(If proceeding, note whether written consent was signed today or will be signed later and outline next steps. If deferring or declining, document the alternative plan, safety net instructions, and follow-up timeframe.)

Attestation

[Attestation statement confirming discussion of indication, proposed procedure, material risks, expected benefits, and reasonable alternatives including no surgery; that questions were answered; that the consenting party expresses understanding and the decision reached; language used with interpreter assistance if applicable.]

(If learner participation is relevant, document that this was discussed and whether permission was given. If blood transfusion is a material possibility for this procedure, document whether this was discussed and any preferences or limitations expressed.)

(For any missing or deferred information, explicitly document status and plan rather than leaving sections blank.)