Consultation Video Consent | The Varis Medical Practice

PATIENT INFORMATION LEAFLET

Name of Doctor: Dr Sanjivani Borgaonkar

Dr Sanivani Borgaonkar is making a recording of her consultation with patients today. This will be used for the doctor’s own education. We thank you for your help with this important part of the doctor’s education and hope that you will agree to your consultation being recorded, but recognise your right not to take part. If you do not want the camera to record your consultation, then all you have to do is tell the doctor. This will not affect your consultation or treatment in any way. If you agree to be recorded you will be asked to sign a consent form.

The recording is as confidential as your medical records and will be kept with the same security. The doctor making the recording will ensure that it is only used for educational and research purposes and that it is erased. It will be used for assessing the doctor’s skill in the consultation, to teach the doctor how to improve and for research – all of which helps patients to get better care.

The recording will be assessed by the doctor as well as NHS Education for Scotland with the aim of giving effective feedback to enable the doctor to offer the best possible service to their patients.

Your data will be held in confidence under the NHS Scotland policies, GMC Standards as well as in accordance with the current as well as any incoming Data Protection Regulations.

As a Data Subject you have a number of rights given to you under the Data Protection Regulations. Specifically relating to the Data Protection Act and the General Data Protection Regulations these rights include;

– The right to be informed as to what will happen with your data

– The right to access your data

– The right to rectification of your data

– The right to erasure

– The right to object

– The right to restricted processing

– The right to data portability

– The right in relation to automated decision making

You also have the right to make a complaint to The Data Protection Officer for NHS Education for Scotland;

Via email – [email protected] OR via post to

The Data Protection Officer
NHS Education for Scotland
Westport 102
Westport
Edinburgh
EH3 9DN

You also have the right to lodge a complaint to the Information Commissioners Office who is the UK’s Supervisory Authority.

You also have the right to lodge a complaint to the Information Commissioners Office who is the UK’s Supervisory Authority.
If, after you have left the surgery you change your mind and wish the consultation to be erased, please contact either the NHS Education for Scotland Data Protection Officer or the Doctor named above in writing, by email, by telephone or in person to ensure that this is done.

Consultation Review Patient Consent Form Part 1

If you are human, leave this field blank.

Name of Consulting Doctor

Name of Patient

Patient e-mail address

Name of person(s) accompanying patient to consultation

Dr Sanjivani Borgaonkar is making a video recording of her consultations. Intimate physical examinations will not be recorded and the camera will be switched off on request. The consultation will be used for the purposes of assessment of the doctor by NHS Education for Scotland, research, learning and teaching and may be required to be copied securely for these purposes.

Dr Sanjivani Borgaonkar is responsible for the security and confidentiality of the recording. If the recording is to leave the practice premises it will be sent registered post or by personal messenger.

Today’s recording will be seen inside your practice and by other doctors working on behalf of NHS Education for Scotland who will give feedback to your doctor on her consultations. The tape will be erased by the recording doctor as soon as possible but definitely not later than five years after the date of the recording.

Your data will be held in confidence under the NHS Scotland policies, the current and incoming Data Protection Regulations as well as the GMC Standards.
If you reconsider once you have left the surgery and want the recorded consultation erased, please contact the Doctor named above in writing, by e-mail, by telephone or in person within 10 days.
Alternatively contact the NHS Education for Scotland Data Protection Officer via e-mail:[email protected] or via post to The Data Protection Officer, NHS Education for Scotland, Westport, 102 Westport, Edinburgh, EH3 9DN

Date

I have read and understand the patient information leaflet

I give my permission for my consultation to be video recorded

I DO NOT GIVE my consent for my consultation to be video recorded

Please state in the box if you wish to limit the use to which the recording might be out and whether you require it to be erased within a specified period of time.

Patient Signature

Person(s) accompanying patient’s signature

Date

reCAPTCHA

Please complete the next form after your consultation