Patienteninformation NT englisch

tirol kliniken
universitätskliniken
innsbruck
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Patientenetikette hier
Name
Geschlecht
Vorname
Geburtsdatum
Dept. of Obstetrics
and Gynaecology
Medical Director:
Univ.-Prof. Dr. Christian Marth
6020 Innsbruck · Anichstraße 35
Website: www.frauenklinik.at
Straße / Nr.
PLZ / Ort
Allg. Geb.-Kl.
Sonder Geb.-Kl. Selbstzahler
Klin. Hinweis
bzw. Diagnose
Patient information and declaration of consent relating to
­ultrasound screening during the first trimester of pregnancy
Dear Patient,
A first trimester ultrasound scan is carried out between the 11th and 13th week of pregnancy to determine the number of babies
and to check that the baby/babies are developing normally. In addition, we can confirm or amend the expected date of birth by
measuring the length of the baby. There are several irregularities that can already be detected or ruled out at this early stage.
If you so wish, we can measure the so-called nuchal translucency (amount of fluid behind the baby’s neck), assess the nasal
bone and check the blood flow in the baby’s heart. These findings, along with a test carried out on the mother’s blood, enable
us to calculate the risk of trisomy 21 (Down syndrome).
A healthy human has, in each body cell, 23 pairs of chromosomes which carry all of that person’s genetic information. All chromosomes exist in pairs, i.e. there are 46 individual chromosomes. In the case of chromosomal abnormalities such as trisomy
13, trisomy 18 and trisomy 21, an extra chromosome, 13, 18 or 21, is present (i.e. 47 chromosomes in total).
The only way to be certain of ruling out a chromosomal disorder is by performing either a placental puncture (CVS – chorionic villus sampling) or an amniotic fluid puncture (amniocentesis). Both these tests, however, carry an approx. 1% risk of
causing miscarriage.
For this reason it is important to determine beforehand the likelihood of your baby having a chromosomal disorder.
After the ultrasound examination and blood test, the results will be discussed in detail with you. If the calculated likelihood
of chromosomal disorders is conclusive enough for you, then there is no need for any further tests. Should you, however, feel
that you need the assurance offered by a definitive test, then either a placental puncture or an amniotic fluid puncture must
be carried out. The advantage of such a test is that it can accurately rule out chromosomal disorders. The disadvantage is that,
in addition to the natural risk of a miscarriage, the puncture causes a miscarriage in 1% of pregnancies.
In addition to calculating the likelihood of Down syndrome, we also assess the baby’s anatomy and can consequently rule
out many abnormalities. This examination, however, cannot determine whether your baby is healthy – it can only test for the
presence or absence of indications of certain disorders. Like every other form of examination, there are certain disorders that
cannot be diagnosed by means of ultrasound screening.
The cost of this examination is only covered by the statutory insurance under certain circumstances. If your ‘Krankenkasse’
does not cover the costs, then you yourself must do so and an invoice for € 127,65 (valid 2016) will be sent to you by the hospital
holding company Tirol Kliniken GmbH.
To summarise:
• The vast majority of babies are born healthy.
• All women, regardless of age, carry a small risk of giving birth to a baby with some disorder.
• The first trimester ultrasound examination is carried out to determine the number of babies, to calculate the expected date
of delivery and to assess the anatomy of the baby/babies.
• It is only at your request that we measure the nuchal translucency, assess other ultrasound indications and carry out a blood
test in order to calculate the likelihood of your baby having trisomy 21.
• The decision as to which examinations should be carried out, and whether further tests should be undertaken should indications of increased risk be present, is entirely yours.
• The examination costs € 127,65 (valid 2016). If these costs are not covered by the statutory insurance offered by your
‘Kranken­kasse’, then they must be covered by yourself and an invoice will be sent to you accordingly.
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Please turn over!
I have understood the patient information sheet and other details which have been explained to me and I would like the following:
Ich habe die Patientinnen-Information/Aufklärung verstanden und wünsche
(Please tick as appropriate )
FF An ultrasound examination to assess the baby (to verify the baby’s heartbeat, to check for multiples, to confirm the
expected date of birth)
eine Ultraschalluntersuchung zur Beurteilung des Kindes (Vitalität, Mehrlingausschluss, Überprüfung des errechneten Geburtstermins)
FF An additional calculation of the likelihood of Down syndrome by means of measuring the nuchal translucency, assessment of other ultrasonographic indications and a blood test.
zusätzlich eine Berechnung des Risikos für Down-Syndrom durch die Messung der Nackentransparenz, Beurteilung anderer sonographischer Zeichen und der Untersuchung meines Blutes
FF Quality assurance: I hereby give my explicit consent that Innsbruck Medical University’s Dept. of Obstetrics and
Gynaecology can request the birth report and results of doctors and clinics consulted subsequently for reasons of
quality control with regard to the ultrasound examination.
Qualitätssicherung: Ich erkläre mich ausdrücklich einverstanden, dass die Univ. Klinik für Gynäkologie und Geburtshilfe Innsbruck zum Zweck der Qualitätskontrolle
der Ultraschalluntersuchung den Geburtsbericht und Befunde des neugeborenen Kindes von den nachbehandelnden ÄrztInnen bzw. Einrichtungen einholen darf
FF Scientific research: Furthermore, I consent to Innsbruck Medical University’s Dept. of Obstetrics and Gynaecology
using this data for scientific purposes, whereby the department pledges, in this case, to make the data anonymous
beforehand.
Wissenschaft: Weiters gestatte ich, dass diese Daten von der Univ.-Klinik für Gynäkologie und Geburtshilfe Innsbruck für wissenschaftliche Zwecke verwendet werden dürfen, wobei sich die Klinik in diesem Fall verpflichtet, die Daten vorab zu anonymisieren
Declaration of consent
I hereby confirm that I have been fully informed about the proposed procedure and the assessment of nuchal transparency by Dr. …………………….................................................................... with the help of the patient information sheet/this information form, the
contents of which have been explained to me in person and in detail, taking into account the results and consequences
of the examination.
I have understood the patient information form I received and the details explained to me and nothing is unclear as regards the procedure and the related consequences. I have had the opportunity to ask questions and any questions that
I have asked have been answered to my satisfaction.
Should you have any questions, please don’t hesitate to contact the Foetal Medicine Unit team at Innsbruck University Hospital’s Dept. of Obstetrics and Gynaecology. Tel.: +43 50 504 23057 or
e-mail: [email protected]
• I agree to the proposed procedure as detailed above and I hereby give my consent.
Mit der vorgesehenen, oben angeführten Behandlung bin ich einverstanden und erkläre hiermit meine Einwilligung.
I agree 
ich stimme zu
I do not agree 
ich stimme nicht zu
• I agree to a calculation of the risk of Down syndrome and I hereby give my consent.
Mit der Berechnung des Risikos für Down-Syndrom bin ich einverstanden und erkläre hiermit meine Einwilligung
I agree 
ich stimme zu
I do not agree 
ich stimme nicht zu
• I agree to the birth report and the newborn baby’s medical records being used for purposes of quality control as
ticked by myself above, and I hereby give my consent.
Mit der vorgesehenen, oben von mir angekreuzten, Einholung des Geburtsberichtes und der Befunde des neugeborenen Kindes zur Qualitätskontrolle bin ich einverstanden und erkläre hiermit meine Einwilligung
I agree 
ich stimme zu
I do not agree 
ich stimme nicht zu
• Furthermore, I agree to this data being used in an anonymous form by Innsbruck University Hospital’s Dept. of Obstetrics and Gynaecology for purposes of scientific research. I am aware that I can withdraw my consent at any time
and that this will carry no adverse consequences.
Weiters bin ich einverstanden, dass diese Daten von der Univ.-Klinik für Gynäkologie und Geburtshilfe für wissenschaftliche Zwecke in anonymisierter Form verwendet
werden dürfen. Ich weiß, dass ich jederzeit meine Einwilligung widerrufen kann, ohne dass dies für mich nachteilige Folgen hat
I agree 
ich stimme zu
I do not agree 
ich stimme nicht zu
• I agree to payment of the costs involved should the statutory insurance offered by the ‘Krankenkasse’ not cover the costs
Mit der Bezahlung der anfallenden Kosten im Falle der Nichtübernahme durch die Krankenkasse bin ich einverstanden
✗.................................................................................................................................................................................
Date/Signature of patient/legal representative/custodial guardian..
Datum/Unterschrift der Patientin/der gesetzlichen Vertretung/SachwalterIn
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Signature of physician
Unterschrift des Arztes/der Ärztin
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