In brief:
- Obtain consent from patients prior to making any audio or video recording of a clinical encounter.
- Discuss with the patient in advance of making any recording, providing information about its purpose and how it might be used. Use of a consent form may be considered.
- Document the consent discussion (and include the consent form if used) in the patient’s medical record.
- Securely store and dispose of the recording (when appropriate).
- Ensure you are aware of any relevant College and institutional policies about recording clinical encounters.
There may be many reasons a physician might wish to record a clinical encounter. While a voice or video recording of a clinical encounter can be invaluable as an accurate and reliable record of the encounter, it is not a substitute for a physician’s clinical notes.
How to obtain the patient’s consent
In general, consent from a patient may be implied or may be specifically expressed either orally or in writing (referred to as express consent). In the context of a physician making a recording of a clinical encounter, the physician is required to obtain express consent, that is, consent that is explicitly given by the patient.
If you intend to record an encounter with a patient, first discuss that intent with the patient. Such a discussion might include the following:
- the reasons for making the recording
- who may be authorized to access the recording and in what context
- the patient's right to refuse, withdraw, or modify consent
- offer to provide the patient with a copy of the recording, if desired
Most privacy legislation in Canada does not specify how consent must be obtained, though some Colleges and institutions may require the use of a consent form when recording a clinical encounter, and privacy legislation in some provinces requires written consent prior to the use of a recording device or camera for any purpose. It is always prudent to request that patients complete a written consent form.
A consent form alone does not constitute the consent of the patient. You should request the patient to complete the form only after you have a discussion about the recording, its intended use, and how the information will be kept secure. Open communication with the patient about the rationale for making a recording will also help ensure that the trust between physician and patient is maintained.
You should add a note about the consent discussion in the patient's medical record. As well, if you have obtained a signed consent form, the completed form should be added to the medical record and a copy may be offered to the patient.
Physicians should be aware that although physicians must obtain informed consent from patients to record clinical encounters, patients are permitted to record their clinical encounters without the physician’s consent.
Secure storage and disposal
Given confidentiality and privacy obligations to protect patient information, it is important to store and dispose of recordings of clinical encounters in a secure manner.
Avoid using personal devices to make recordings of patient conversations. Rather, consider using a designated workplace device for such recordings.
Permanently delete recordings from the device as soon as you have uploaded them to a secure location (e.g. the patient’s medical record). Ensure encryption software is installed on any device on which recordings are stored.
Recordings and the medical record
A recording made in the context of providing patient care is likely to be considered part of the clinical record. As such, its existence and storage location should be documented in the medical record, and if possible uploaded to the medical record itself. The recording should be stored, along with the medical record itself, for the required or recommended period of time.
Once part of the medical record, any copies of the recording should be destroyed in a manner that maintains confidentiality.
