Policy AD-200 Informed Consent for Use of Patient Images for Non-Patient-Care Purposes 2021-07-16

Purpose

The purpose of this policy is to respect and protect patients’ privacy, as well as to meet The Joint Commission requirement to honor the patients’ right to give or withhold informed consent.

Policy

Occasionally, Westside Family Healthcare (Westside) creates or obtains recordings, films, or other images of patients for purposes other than patient care. Westside honors the patient’s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care.

Westside obtains and documents informed consent prior to using patient images for purposes other than patient care. The informed consent form notifies the patient of his or her right to request cessation of the production and/or use of images of the patient. Westside accommodates the patient’s right to rescind consent before the recording, film, or image is used.  

Before engaging in the creation or production of patient images for reasons other than patient care, any person who is not already bound by the organization’s confidentiality policy will sign a confidentiality statement to protect the patient’s identity and confidential information.

Scope

This policy applies to all Westside employees and to anyone engaged in the creation and production of Westside patient images for reasons unrelated to patient care on behalf of Westside.

Definitions

Recordings, Films, or Other Images - This term refers to photographic, video, digital, electronic, or audio media. (The Joint Commission)

Procedures

Before creating or obtaining recordings, films, or other images of a patient for purposes other than patient care, for either internal or external use, Westside obtains the patient’s signature on the Release for Use of Photographs and Video.

Before creating, producing or using recordings, films, or other images of a patient for purposes other than patient care, for either internal or external use, anyone who is not already bound by policy AD-101 Confidentiality will sign a confidentiality statement to protect the patient’s identity and confidential information.

References

1. Standard from The Joint Commission (TJC), Rights and Responsibilities of the Individual (RI) chapter, Comprehensive Accreditation Manual for Ambulatory Health Care (CAMAC), January 1, 2021.  
   1. RI.01.03.01: The organization honors the patient's right to give or withhold informed consent.
      1. EP 3 – The organization obtains and documents informed consent in advance when it makes and uses recordings, films, or other images of patients for internal use other than the identification, diagnosis, or treatment of the patient (for example, performance improvement and education).  Note: This element of performance does not apply to the use of security cameras.

TJC Standards FAQ: Videotaping or Filming - Circumstances When Informed Consent is Required, Under what circumstances is an informed consent required prior to recording, filming or photographing patient care? (https://www.jointcommission.org/standards/standard-faqs/ambulatory/rights-and-responsibilities-of-the-individual-ri/000001700/)