Obtaining Consent
Before using EncompassScribe to capture audio during a patient visit, you should obtain consent from the patient and from any other person whose voice may be recorded. Some jurisdictions require all parties to consent before audio recording. Other laws, rules, or professional obligations may require notice or consent before using AI-assisted documentation tools. Practices are responsible for determining and complying with the laws, regulations, payer requirements, and organizational policies applicable to their practice, patients, and location.
Take a moment to explain why the tool is being used, how the provider will use the output, and that the provider remains responsible for reviewing, editing, and finalizing the medical record. Do not use Eyefinity EncompassScribe for a visit if the patient or another person whose voice may be captured declines or withdraws consent.
Eyefinity Encompass includes workflows that may support obtaining and retaining written consent when your practice determines written consent is required or appropriate.
What do you want to do?
While your practice needs to develop a workflow based on the needs of the practice, the following workkflow is recommended:
- Confirm whether written consent is required or appropriate for the visit based on your practice’s legal and operational requirements.
- Before beginning audio capture, notify the patient and any other person present that audio may be captured to support AI-assisted clinical documentation.
- Obtain consent from the patient or the patient’s authorized personal representative, as applicable, and from any other person whose voice may be captured.
- Document the patient’s consent or refusal in the patient record using the workflow selected by your practice.
- Stop or pause audio capture if consent is declined or withdrawn and use an alternative documentation method.
The following sample consent covers audio recording or audio capture and AI-assisted documentation. It is provided as a template only and is not legal advice. Before using it, your practice should review applicable recording, privacy, security, AI disclosure, consent, patient-record, and professional requirements and adapt the consent to meet the needs of your jurisdiction and practice. Your practice should also consider whether additional language is needed for minors, personal representatives, caregivers, interpreters, staff, or other individuals who may be present during the visit.
PATIENT CONSENT FOR AUDIO RECORDING AND AI-ASSISTED DOCUMENTATION
Purpose of This Consent
EncompassScribe by Eyefinity is a tool used by your eye care provider to assist with clinical documentation during your visit. This tool may use ambient audio technology and artificial intelligence (“AI”) to capture and summarize portions of your interaction with your provider to support accurate and efficient medical recordkeeping.
What You Are Consenting To
By selecting “I Consent,” you acknowledge and agree to the following:
1. Audio Capture. Your visit may be audio recorded for the purpose of creating clinical documentation.
2. AI-Assisted Documentation. The recorded audio may be processed using AI technology to generate a draft clinical note or transcription to assist your provider.
3. Provider Review and Control. Your provider will review, edit, and finalize all documentation. The AI tool does not make medical decisions or replace your provider’s professional judgment.
4. Use and Protection of Information. Any recordings and related documentation will be handled in accordance with applicable privacy and security laws, including the Health Insurance Portability and Accountability Act (HIPAA), and will be used solely for treatment, payment, and healthcare operations unless otherwise permitted or required by law.
5. Voluntary Participation. Your participation is voluntary. Your decision to consent or decline will not affect your access to care, treatment, or benefits.
6. Right to Decline or Withdraw. You may decline this consent or withdraw it at any time before or during your visit by notifying your provider. If you withdraw consent, recording will stop, and alternative documentation methods will be used.
Consent Acknowledgment
☐ I CONSENT to the audio recording and AI-assisted documentation of my visit as described above.
☐ I DO NOT CONSENT to the audio recording and AI-assisted documentation of my visit.
Patient Name: ___________________________
Date: ___________________________
If completed electronically, your selection constitutes your electronic signature.
The practical way to capture written consent is through the waivers and consents functionality in Encompass.. Depending on your practice workflow and Encompass configuration, you may administer patient acknowledgment in one of the following ways:
- Waivers are administered to all patients through the Kiosk app while they are in the waiting room. To learn more, go to Creating and Editing Waivers.
- Consents are administered in the exam room as needed using the iPad app. To learn more, go to Adding and Editing Consent Forms.
- PDF forms are highly customizable forms that can be administered as waivers or consents. To learn more, go to Creating Fillable PDF Forms.
When patient acknowledgment is captured through an Encompass workflow, the acknowledgment is retained with the patient record.
The following sample responses may help providers answer patient questions when asking for consent. Practices should adapt these responses to their own workflow, privacy practices, and applicable legal requirements.
| Question | Answer |
|---|---|
|
What is the purpose of the recording? |
It helps create draft documentation for my review so I can focus more of my attention on your visit. I will review, edit, and finalize the medical record. The tool does not make medical decisions or replace my professional judgment. |
|
Where is my voice saved? |
This tool processes your voice on this device and turns our conversation into text. The recoding itself is deleted automatically after the transcription is complete. |
|
If I decide I'm not comfortable, can I change my mind? |
Yes, I can stop or pause the audio capture whenever you'd like. If you do not want audio captured, I will use another documentation method. |
|
What if I say something that messes up the recording. |
Don't worry. This tool is really good at recognizing which one of us is the doctor, and it's designed to filter out other conversations. So just talk to me like you normally would. |
| Will the AI make decisions about my care? |
No. I remain responsible for your care and for the final medical record. The tool is used to assist with documentation only. |