29.2 Confidentiality, Informed Consent, Scope of Practice & Ethical Standards

Confidentiality in daily practice

Protected health information is any information that identifies a patient and relates to their health, care or payment. In an eye clinic that includes far more than the chart:

• The appointment list on a front-desk monitor visible to the waiting room
• A name called out in the waiting area alongside a diagnosis
• A chart or screen left open on an unattended workstation
• Photographs and video, which are directly identifiable
• Conversation in corridors, lifts, the cafeteria and the car park
• The whiteboard listing today's surgical cases

Rules that translate the principle into behaviour:

1. Access only what your role requires. Looking up a colleague's, a neighbour's, a family member's or a public figure's record out of curiosity is a disciplinary and reportable offence even when nothing is disclosed, and access logs make it detectable.
2. Lock or log off every workstation when you step away, even briefly.
3. Angle screens away from public sightlines.
4. Verify identity and authority before disclosing anything by telephone — including to someone claiming to be a relative.
5. Release records only with written authorisation, or where a treatment relationship or statutory duty applies.
6. Do not discuss patients where you can be overheard, and never on social media even in anonymised form — eye conditions are often distinctive enough to identify someone.
7. Dispose of paper containing identifiers in confidential waste, never ordinary bins.
8. Report a breach immediately through the correct channel; concealment compounds the harm.

A patient may decline to have a family member present or informed. Ask, rather than assuming that the person who walked in with them is entitled to hear the results.

Informed consent

Informed consent is a process, not a signature. Its elements:

Who obtains it. Consent for a procedure is obtained by the clinician who will perform it, because only they can discuss the risks and alternatives authoritatively. A technologist may:

• Witness a signature, confirming the identity of the signer and that they signed voluntarily
• Confirm the patient has no remaining questions and fetch the clinician if they do
• Provide written information prepared for the purpose
• Explain and obtain agreement for the tests the technologist performs, such as dilation or photography

A technologist must not obtain consent for a surgical or invasive procedure they will not perform, and must not answer risk questions beyond their knowledge. "I don't want to guess at that — let me get the doctor to answer it properly" is always the correct response.

Special situations:

• Minors — consent from a parent or legal guardian, with the child's assent sought according to age and local law.
• Impaired capacity — a legally authorised representative, following local law and the patient's advance directives.
• Language barriers — a professional interpreter, documented.
• Emergencies — treatment necessary to preserve life or sight may proceed under the doctrine of implied consent when the patient cannot consent and no representative is available.
• Photography or video for teaching, publication or marketing — requires separate explicit consent, which may be withdrawn.
• Research — a separate, formal consent process governed by the ethics committee.

Scope of practice

Scope of practice is the set of tasks a person is trained, competent and authorised to perform. It is defined by three overlapping constraints: local law and regulation, institutional policy and delegation, and individual competence.

Within the COMT scope, given appropriate delegation: history taking, visual acuity, refractometry and refinement, retinoscopy, keratometry, lensometry, tonometry, visual fields, pupil assessment, motility measurement, biometry and echography within certification, imaging and photography, contact lens fitting under supervision, instillation of diagnostic drops per protocol, patient education about procedures and medication use, surgical assisting where trained, and documentation.

Outside the technologist's scope: making a diagnosis, giving a prognosis, prescribing, changing or stopping a medication, interpreting a test result for the patient, deciding whether surgery is indicated, and performing any procedure for which the technologist is not trained and authorised.

The grey area that causes trouble is the patient who asks a clinical question you probably know the answer to. Knowing the answer is not the same as being authorised to give it, and a technologist's answer carries clinical weight with the patient. The safe response acknowledges the question and routes it correctly.

Delegation. A clinician may delegate a task, but delegation does not transfer competence. A technologist may decline a task they are not trained to perform, and should — accepting it is the error, not refusing it.

Ethical and professional standards

Core obligations:

1. Patient welfare first, ahead of throughput, convenience or commercial interest.
2. Honesty — including about your own errors. Report a mistake immediately; a wrong drop or a wrong-eye measurement is recoverable, a concealed one may not be.
3. Competence — practise within it, and maintain it. IJCAHPO requires 36 continuing education credits every 36 months for COMT recertification precisely because competence decays.
4. Respect — for patients, families and colleagues, regardless of background, behaviour or ability to pay.
5. Non-discrimination.
6. Professional boundaries — no personal relationships with patients, no accepting significant gifts, no social media contact with patients.
7. Conflicts of interest — disclose them. Vendor relationships, incentives to recommend particular products and financial interests in a service must be transparent, and must not drive clinical recommendations.
8. Accurate credentialing — never represent yourself as holding a credential you do not hold, and never use "doctor" or a title that could mislead. Introduce yourself accurately: "I'm one of the ophthalmic technologists."
9. Duty to speak up about unsafe practice, whoever is responsible, through the proper channel.

Certification-specific ethics. IJCAHPO requires candidates to accept a non-disclosure agreement as part of every examination. Disclosing examination content, reconstructing questions for others, or using material derived from someone else's recall is a violation that can invalidate certification. Recertification credits must be genuinely earned, not fabricated, and a course topic may be counted only once per 36-month cycle.

Mandatory reporting and duties

Local law defines these and they vary by jurisdiction, but technologists should know that the categories exist and where the clinic's policy is:

• Suspected child, elder or vulnerable adult abuse — signs may present as ocular trauma with an inconsistent history, retinal haemorrhages in an infant, or repeated unexplained injury.
• Certain communicable diseases.
• Visual impairment affecting driving, where local law imposes a notification duty.
• Adverse events and device failures, reported through the applicable safety reporting system.

The technologist's duty is to report the concern internally to the responsible clinician and follow the clinic's protocol, not to conduct an investigation.