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Preoperative workflow · Step 5

A consent sheet that applies to this person only

medudoc generates each digital informed consent sheet – the Informed Consent Sheet (IC Sheet) – individually from general information on the procedure and statements from the medical history. Interdisciplinary, bilingual and, at the end, a single PDF/A as complete evidence.

Bilingual consent sheet with the German original on the left and the translation on the right, a highlighted section from the medical history, a physician's addition, two signatures and the appendix with consent trail and medical history.

Individual

Not a form, but one document per person

Generic sheets contain risks that are not relevant to this person and leave out what is relevant. medudoc compiles the sheet from general information and the statements from the medical history – so the document itself is already individual.

  • Medical history
  • Procedure
  • Risk profile
  • Derived from the medical history

    Pre-existing conditions, medication and allergies determine which notes and risk passages appear in the sheet.

  • Matched to procedure and technique

    The type of procedure and the anaesthetic technique determine risks, preparation and instructions for patients.

  • Interdisciplinary in one sheet

    Surgery and anaesthesia are in one document – without separate sheets and without a second signature.

  • Digital annotation

    Physicians add to the sheet before signature. Their additions are part of the document and evidence the individual patient education.

  • Reviewed content

    All content comes from medudoc's medical editorial team and is reviewed for currency at least once a year.

Bilingual

Two languages, one document

For patients who speak another language, the German original is on the left and the translation on the right – in one sheet. The physician can see at any time what the patient is reading.

languages for patient education content
23
document instead of two separate versions
1
the original German version
Left
the translation as an aid to understanding
Right
  • medudoc provides patient education content in 23 languages. Legally binding consent is given on the German original; the translation helps patients whose first language is not German to understand it.
  • Fewer documents to file and no searching for the right language version.
A hand signs a document on a tablet with a finger.

Sign once everything is understood

Patients read the sheet at their own pace, together with the patient education video. They sign after the discussion – at home in the browser or on site.

Electronic signature

Sign in the way that suits your process

medudoc supports all three levels of electronic signature under the eIDAS Regulation (EU) No 910/2014. Your hospital chooses the level – in the browser or on site on a signature pad.

  • SES

    Simple electronic signature

    Low-threshold, for processes in which easy access is the priority.

  • AES

    Advanced electronic signature

    Unambiguously linked to the signatory and bound to the document in a tamper-proof way.

  • QES

    Qualified electronic signature

    With a qualified certificate; legally equivalent to a handwritten signature (Art. 25(2) eIDAS Regulation).

  • On site

    Signature pads during consultations

    In the pre-anaesthesia clinic, patients sign on signotec signature pads – directly in the digital sheet.

One PDF/A

The complete evidence in one document

Consent involves more than the signed sheet. medudoc attaches the consent trail and the documentation of the medical history – one PDF/A contains the complete evidence.

  1. 1

    General information

    Procedure, process, alternatives and typical risks from medudoc's medical editorial team.

  2. 2

    Statements from the medical history

    Notes derived from the information the patient has provided.

  3. 3

    Physician's annotation

    Additions by the physician from the consent discussion.

  4. 4

    Electronic signatures

    Signatures of patient and physician at the chosen eIDAS level.

  5. 5

    Consent trail

    Complete documentation of the patient education process: opening of the sheet, video sections watched, timestamps.

  6. 6

    Medical history

    The documentation of the medical history data captured.

Patients can view and download all signed documents in the patient portal – as copies under Section 630e(2), sentence 2 of the German Civil Code (BGB).

Process

From medical history to signed sheet

  1. 1. Medical history and approval

    The medical history is complete; physicians specify the procedure and anaesthetic technique.

  2. 2. Generate the sheet

    medudoc generates the sheet in a few seconds – interdisciplinary and bilingual if required.

  3. 3. Read in advance

    Patients read the sheet together with the patient education video at their own pace and note down questions.

  4. 4. Discussion and signature

    In the consent discussion, the physician adds to the sheet; afterwards, both sign electronically.

  5. 5. Archive and hand over

    The PDF/A goes to the hospital information system (HIS) or archive system.

The personal discussion remains the core element – the sheet documents it.

See a personalised sheet from your specialty

In a demo, we show you a consent sheet with statements from the medical history, annotation and consent trail – bilingual too.

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