Informed consent document for ophthalmological teleconsultation at IMO

IDENTIFICATION AND DESCRIPTION

The World Health Organization (WHO) defines Telemedicine as the provision of health services in which distance is a critical factor, where health professionals use information technology and ICT communications for the exchange of information. valid, for the diagnosis, treatment and prevention of diseases or damages, as well as the permanent training of health professionals and in research and evaluation activities, in order to improve the health of individuals and the community. The information may be used for diagnostic guidance, monitoring, and / or education, and may include any of the following:

 • Patient's medical records

• Medical images

• Live two-way audio and video

• Medical device output data and sound and video files

The electronic systems used will attempt to incorporate security protocols to protect the confidentiality of patient identification and photos-data and will include measures to safeguard the data and ensure its integrity of information.

PURPOSE OF THE PROCEDURE AND BENEFITS

• Improved access to medical care by allowing a patient to keep in their location while the professional and health teams provide information from a distant site.

• Limit the spread of COVID-19 and other communicable diseases.

• Possibility of obtaining the consultation of a distant specialist doctor without traveling.

• Allow medical evaluation and management of patients who cannot travel.

POSSIBLE RISKS

As with any medical procedure, there are risks associated with using telemedicine. These risks include, but are not limited to:

• The information transmitted may not be sufficient to allow appropriate medical decisions to be made. For example, certain parameters of the eye exam cannot be tested remotely, such as eye pressure. Also, there may be poor resolution of images. This can cause a delay in medical evaluation and treatment.

• Security protocols for electronic systems can fail and cause a violation of the privacy of personal health information.

• Lack of access to complete medical records can lead to adverse drug interactions or allergic reactions or other medical errors.

ALTERNATIVES

In-person consultation.

RISKS ADMISSION BY THE PATIENT

Due to its particular characteristics, telemedicine ophthalmological consultation cannot replace a face-to-face medical consultation.

By signing this form, I understand that:

They have explained to me and I have understood that it is not possible to carry out any medical-ophthalmological examination, and that the specialist can only be guided by my statements and / or the images that I send him (case of video-assistance or sending of eye images), to try to reach a presumptive diagnosis and not necessarily of certainty, for which the ophthalmologist's margin of diagnostic error is much greater. I am fully aware of this and accept it with all its consequences.

The laws that protect the privacy and confidentiality of medical information also apply to telemedicine, and that no information obtained from the use of telemedicine will be disclosed to researchers or other entities without my agreement.

I have the right to withhold or withdraw my agreement to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. 

Telemedicine may involve the electronic communication of my personal medical information to other medical professionals located elsewhere, including out of state.

I understand that results from the use of telemedicine cannot be guaranteed.

Consent. By signing below, you agree that:

• You have read this informed consent form or someone has read it to me.

• You understand the information on this informed consent form and all of your questions have been answered.

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