Due to the nature of this procedure, we always clean the transducer with a high-level disinfectant after each use. We then take the additional precaution of covering the transducer with a single-use transducer cover or a condom.

E. Specific risks for you in having this procedure(Sonographer/Doctor to document in space provided. Continue in Medical Record if necessary)

F. Risks of not having this procedure(Sonographer/Doctor to document in space provided. Continue in Medical Record if necessary)

G. Alternative procedure, treatment or investigation options

(Sonographer/Doctor to document in space provided. Continue in Medical Record if necessary)

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A. Does the patient have capacity? Yes   GO TO section B  No   COMPLETE section A

i. a) Is the patient aged under 18 years? Yes (document parent/guardian name below) No   GO TO iiYou must adhere to the Advance Health Directive (AHD) or the consent obtained from a substitute decision-maker.ii. a) Does the patient have an AHD that is applicable to the

procedure, treatment or investigation? Yes   No   GO TO iii

b) If yes, has the AHD been sighted and a copy in the medical record? Yes   No   GO TO iii

iii. a) Substitute decision-maker (select one only): Attorney(s) for health matters under an Enduring Power of Attorney or AHD Tribunal-appointed guardian Statutory Health Attorney If none of these, the Office of the Public Guardian must provide consent (ph: 1300 653 187)

Name of substitute decision-maker(s) or parent/guardian:

Signature of substitute decision-maker(s) or parent/guardian:

Relationship to the patient (e.g. substitute decision-maker or parent/guardian)

Date: Phone number:

B. Does the patient need Interpreter/

cultural services?i. a) Is a language interpretation service required? Yes   No   GO TO ii

b) If yes, is a qualified Interpreter present? Yes (complete section J)   No   N/A

ii. a) Is a cultural support person required? Yes   No   GO TO section C

b) If yes, is a cultural support person present? Yes   No   N/A

C. Condition and treatmentThe sonographer/doctor has explained that:I require a transvaginal ultrasound scan. The insertion of the transducer into the vagina allows a closer view of the pelvis, providing detailed images of the pelvic organs.D. Risks and complications of a

transvaginal ultrasoundThere are no known risks of performing transvaginal ultrasound. It is normal to feel mild pain and discomfort during a transvaginal ultrasound scan. If scanning is performed over an area of tenderness you may also feel some pressure. If the scan causes you anything more than mild pain, please let the sonographer/doctor know.

(Affix identification label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Transvaginal Ultrasound Consent

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H. AnaestheticThis procedure may require an anaesthetic (doctor/clinician to document type of anaesthetic discussed)

I. Patient/Substitute decision-maker consentI acknowledge the sonographer/doctor has explained:• the risks and benefits and I understand it, including the risks

specific to me;• my/the patient’s risks of not having the procedure;• a sonographer/doctor other than the consultant/specialist

may conduct/assist with the clinically appropriate procedure/treatment/investigation/examination. I understand this could be a sonographer/doctor undergoing further training. I understand that all surgical trainees are supervised according to relevant professional guidelines;

• I/the patient was able to ask questions and raise concerns with the sonographer/doctor about my/the patient’s proposed procedure and its risks. My questions and concerns have been discussed and answered to my satisfaction;

• I/the patient understand I have the right to change my mind at any time, including after I have signed this form ;

• I/the patient understand image(s) may be recorded as part of and during my procedure and that these image(s) will assist my treating doctor.

Student examination/procedure for educational purposesFor the purpose of undertaking professional training, a student(s) may observe the medical examination(s) or procedure(s) and may also, subject to patient consent, perform an examination(s) or assist in performing the procedure(s) on a patient while the patient is under anaesthetic. This is for education purposes only. A student(s) who undertakes an examination(s) or assists in performing the procedure(s) will be under the supervision of the treating doctor, in accordance with the relevant professional guidelines.For the purposes of education I consent to a student(s) undergoing training to:• observe examination(s)/procedure(s) Yes  No• assist and/or perform examination(s)/ Yes  No

procedure(s)Student - this may include medical, nursing, midwifery, allied health or ambulance students.

I have received the following information sheet(s): ‘Transvaginal ultrasound’

On the basis of the above statements,I consent to having this procedure.Name of patient:

Signature: Date:

I consent to:Name of patient having procedure:

Name of substitute decision-maker:

Signature: Date:

J. Interpreter’s statementI have:

Provided a sight translation Translated as per clinician explanation in:

Patient’s language:

of this consent form and assisted in the provision of any verbal and written information given to the patient/substitute decision-maker by the doctor/clinician.

Name of patient:

Language of patient:

Name of Interpreter service:

Name of Interpreter:

Interpreter’s signature: Date:

K. Sonographer/Doctor/Delegate statementInformation for sonographer/doctor/delegate:The information contained within this form is not, and is not intended to be, a substitute for direct communication between the sonographer/doctor/delegate and the patient/substitute decision-maker regarding the investigation described in this form. I have explained to the patient all the content in this patient consent form and I am of the opinion that the patient/substitute decision-maker has understood the information. Name of sonographer/doctor/delegate:

Designation:

Signature: Date:

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Given name(s):

Address:

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Transvaginal Ultrasound Consent

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4. During the procedureThe lights in the room will be dimmed so the images can be clearly seen on the ultrasound display screen.

A protective cover will be placed over the transducer and lubricating gel will be applied to it, to ease insertion of the transducer.

You will be asked to lie on an examination couch. A sheet will be provided to cover you. You will be asked to bend your legs and the transducer will be inserted into the vagina. The sonographer/doctor may ask you to assist in inserting the transducer.

The sonographer/doctor will need to move the transducer throughout the examination to visualise the pelvic structures. If you have any concerns during the examination, please inform the sonographer/doctor performing the examination.

5. What are the risks of this procedure?There are no known risks of performing transvaginal ultrasound.

Due to the nature of this procedure, we always clean the transducer with a high-level disinfectant after each use. We then take the additional precaution of covering the transducer with a single-use transducer cover or a condom.

6. What are the risks specific to me?There may be additional risks specific to your individual condition and circumstances. Please discuss these with your sonographer/doctor and ensure these risks are written on the consent form before you sign it.

If you choose not to have the procedure you will not be required to sign a consent form.

1. What is this procedure and how will it help me?

Figure 1: A transducer is placed inside the vagina, allowing detailed images of pelvic organs such as the uterus and ovaries.

Ultrasound scans use high frequency (ultrasonic) sound waves to see internal organs. Ultrasound waves are transmitted by a transducer and relayed back to the ultrasound machine to produce images on a display screen.

A transvaginal ultrasound scan involves placing a specially designed transducer inside the vagina. The uterus and ovaries lie deep beneath the abdominal surface. The insertion of the transducer into the vagina allows a closer view (and more detailed images) of these pelvic organs. A transvaginal scan usually takes 10–15 minutes, but can be stopped at any time if you do not wish to continue.

2. Will there be any discomfort?It is normal to feel mild pain and discomfort during a transvaginal ultrasound scan. If scanning is performed over an area of tenderness you may also feel some pressure. If the scan causes you anything more than mild pain, please let the sonographer/doctor know.

3. Preparation for a transvaginal ultrasound scanYou will be asked to go to the toilet and empty your bladder before the transvaginal scan. You may need to change into a hospital gown. If you are wearing a tampon or moon cup, it will need to be removed.

Give this patient information sheet to the patient or substitute decision-maker(s) to read carefully and allow time to ask any questions about the procedure.

Transvaginal Ultrasound Consent Informed consent: patient information

Department of Health Transvaginal Ultrasound Consent Information Sheet SW9459 v2.00 12/2018 Page 1 of 2

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8. Questions to ask my sonographer/doctor (continued)

9. Contact us

7. Who will be performing my procedure?A doctor other than the consultant/specialist may conduct/assist with the clinically appropriate procedure/treatment/investigation/examination. I understand this could be a doctor undergoing further training, and that all trainees are supervised according to relevant professional guidelines.If you have any concerns about which doctor/clinician will be performing the procedure, please discuss with the doctor/clinician.For the purpose of undertaking professional training in this teaching hospital, a student(s) may observe the medical examination(s) or procedure(s).Subject to your consent, a student(s) may perform an examination(s) or assist in performing the procedure(s) while you are under anaesthetic. This is for education purposes only. A student(s) who undertakes an examination(s) or assists in performing the procedure(s) will be under the supervision of the treating doctor, in accordance with relevant professional guidelines.If you choose not to consent, it will not adversely affect your access, outcome or rights to medical treatment in any way. You are under no obligation to consent to an examination(s) or a procedure(s) being undertaken by a student(s) for education purposes.

8. Questions to ask my sonographer/doctorPlease ask the sonographer/doctor if you do not understand any of the information given in this consent information sheet or any other information about your condition and the proposed transvaginal ultrasound scan.

Department of Health Transvaginal Ultrasound Consent Information Sheet SW9459 v2.00 12/2018 Page 2 of 2