Standards › Standard 27 › Standard operating procedures (SOPs)
Procedure · TEL-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 27.13
At a glance
- The clinician confirms the patient’s identity at the start of every remote consultation (TEL-FRM-004).
- The clinician confirms who else is present and whether the consultation is private.
- Identity is checked against a second identifier, not the voice or face alone.
- A consultation is not held if identity or privacy cannot be confirmed.
- Stop and get help straight away if: a consultation is held with a family member pretending to be the patient.
1. Purpose
To make sure the right patient receives the care, and the consultation is private (27.13).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
In a remote consultation, the clinician cannot see who is on the other end. Confirming the patient’s identity at the start protects against the wrong person receiving care, or a record being made for the wrong patient.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Telemedicine service lead | Owns the identity and privacy rule | Clinician or manager |
| Treating clinician | Confirms identity and privacy at each consultation | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Confirm identity.
- Confirm the patient’s identity with a second identifier at the start of the consultation.
Key point: Confirmed.
Step 2. Confirm privacy.
- Ask who else is present and whether the patient can speak privately.
Key point: Confirmed.
Step 3. Record or stop.
- Record the checks on TEL-FRM-004, or stop the consultation if they cannot be confirmed.
Key point: Recorded.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Consultations with identity and privacy recorded | 100% | Monthly | Telemedicine service lead | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| TEL-FRM-004 | Remote consultation identity and privacy check | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Recommendations on digital interventions for health system strengthening (2019) and the WHO Ethics and governance of artificial intelligence for health (2021). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)