One of the features of the COVID-19 pandemic is the increased use of remote consultation methods. This has been particularly helpful in maintaining social distancing measures, reducing unnecessary travel and helping to protect the most vulnerable.
Many remote consultations, including video conference calls, are not recorded, and reach a satisfactory conclusion through dialogue and (if in video mode) the patient illustrating their dental complaint - for example, by demonstrating the site and extent of a swelling. They are the equivalent of a face-to-face consultation.
The summary of the consultation, including a note that it is a video consultation, and notes of anything discussed with the patient and seen in the video, are then recorded in the clinical records in the usual way.
However, there can be dento-legal pitfalls along the way, and there are some of the factors you should keep in mind.
Make sure you have read and are thoroughly familiar with the GDC information on High level principles for good practice in remote consultations and prescribing.
The guidance applies to photographs as well as other audio and visual recordings. If you work in an NHS trust you should also familiarise yourself with, and follow, any relevant information governance policies.
Consent and confidentiality
If you're planning to make a recording of a consultation, we advise taking the following steps.
- Tell the patient you plan to record the consultation. The patient should give consent to the recording being made. If they decline, this should be respected. The video consultation can still go ahead without it being recorded.
- The recording should become part of the clinical records, so needs to be stored securely and be retrievable. The process of obtaining and documenting consent should include explaining why the video consultation will help in providing clinical care.
Explain to the patient how the clinical records, including the copy of the video, will be securely stored and that they won't be used for any other purpose without their express permission. Document these discussions and decisions in the clinical records.
Where the patient is a child who lacks capacity to make a decision about a video of them being made by you, you'll need the permission of someone with parental responsibility.
If the patient is an adult who lacks capacity, you must be satisfied the video recording is necessary, will be of benefit to them, and is in their best interests.
In this situation, it's important to remember there may be someone who has legal authority to act on the patient's behalf in healthcare decisions, and you should seek their agreement.
As with a face-to-face consultation, you need to ensure you carry out the consultation in an environment where you can maintain patient confidentiality.
Receipt and storage
Make sure there are appropriate security arrangements in place when personal information is stored, sent or received electronically. This includes video images and photographs.
Agree with the patient how any additional information will be sent to you. If this is by email, it should be to your secure, NHS encrypted email account (usually nhs.net email), used in accordance with your organisation's policy. Upload the information to the patient's records and delete the email and any attachments from your account.
Some practices and NHS organisations may use specific software to allow receiving information by text, and the same principles apply.
Need more advice? See all of our coronavirus dento-legal guidance.
This page was correct at publication on 12/11/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.