Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

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3.1.20 Clinical Photography/Digital Imaging

  • Policy

    • California Correctional Health Care Services (CCHCS) shall ensure availability of digital imaging equipment at California Department of Corrections and Rehabilitation (CDCR) institutions for health care staff to monitor the stages of healing or progression of disease, detect the presence of complications, and review the effectiveness of treatment. Digital imaging equipment shall not be used to document use of force incidents; however, consistent with this policy, digital imaging may be used for clinical management of any illness or injury, including those associated with use of force incidents.

  • Purpose

    • To provide guidelines for the use of digital imaging equipment for clinical documentation and to provide baseline and ongoing assessment for the surveillance and monitoring of medical conditions or disease status.

    • To serve as an adjunct to the written assessment.

    • To provide guidance for safeguarding the digital imaging equipment from tampering, loss, or destruction.

  • Responsibility

    • Statewide

      • CCHCS and CDCR departmental leadership at all levels of the organization shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available to successfully apply this policy and procedure.

    • Regional

      • Regional Health Care Executives are responsible for application of this policy and procedure at the subset of institutions within an assigned region.

    • Institution

      • The Chief Executive Officer has overall responsibility for compliance with and ongoing oversight of this policy and procedure.

      • The Chief Medical Executive and Chief Nurse Executive are responsible for the overall daily operations.

      • The Health Information Management staff are responsible for ensuring all established rules and guidelines for the release of health information and record retention of digital images are followed.

      • Information Technology (IT) staff are responsible for ensuring equipment is maintained and in good working order.

  • Procedure

    • Camera Storage and Maintenance

      • The camera shall only be used by designated health care staff for conducting medical assessments, including skin or other anatomical area assessments and/or wound management.

      • The camera shall be affixed with a CCHCS asset tag for tracking purposes.

      • The camera shall be added to the clinic’s Master Tool Inventory.

      • The camera and its accessories (e.g., USB cable and wound measuring rulers), or a state issued cell phone, shall be stored in a locked drawer separate from any other items located in the locked medication room of one or more of the following areas:

        • Registered Nurse Line clinic of every yard

        • Triage and Treatment Area

        • Correctional Treatment Center

        • Outpatient Housing Unit

        • Licensed inpatient units

        • Telemedicine clinic areas that have locked telemedicine carts with cameras

      • The drawer in the locked medication room shall be clearly labeled with the drawer contents.

      • The camera shall be kept in the locked drawer until the time of use.  After each use, the camera shall be cleaned, according to manufacturer instructions, placed in the carrying case, and returned to the designated drawer.

      • The camera and its accessories shall not be left exposed to the environment or left unsecured.

      • Nursing staff shall account for the camera and its accessories at the beginning of each shift and document the presence of the camera, by signing the Tool Inventory Report.

      • In the event of a broken or missing camera or accessory, nursing staff shall immediately notify the Supervising Registered Nurse (SRN) II and unit custody officer, and search the immediate area.

        • The SRN II shall notify the Watch Commander.  The nursing staff shall submit a memorandum to the following staff:

          • Watch Commander (missing camera only)

          • SRN II

          • SRN III

          • Tool Control Officer

          • IT (for cameras that are broken or not in proper working condition)

          • Information Security Office (for missing cameras)

    • Cell Phone

      • If cell phones are used, only state-issued cell phones with CCHCS asset tags, belonging to the designated health care staff obtaining the digital image, are allowed for conducting medical assessments, including skin or other anatomical area assessments and/or wound management.

    • Clinical Photograph/Digital Image Quality and Accuracy

      • Designated health care staff shall obtain a digital image of anatomical/wound areas to be evaluated on initial assessment and if any changes are identified to assist in assessment and management.  Digital images are an adjunct to assessment documentation and serve only to support the written wound documentation and does not replace it.

      • Unless clinically indicated, digital images shall not be obtained solely for the purpose of documenting a use of force incident.  Refer to the Department Operations Manual, Chapter 5, Adult Custody and Security, Article 2, Use of Force.

      • Digital images taken as a part of the health record shall:

        • Be recorded only on digital cameras and/or cell phones owned by CCHCS and designated solely for clinical management.  They shall not be taken on cell phones or cameras that are the personal property of staff.

        • Not be stored on external or removable memory devices (e.g., flash drives).

      • Prior to taking any digital images , the designated health care staff shall obtain the following patient consent:

        • Written Consent: Designated health care staff shall ensure a CDCR 7120, Informed Consent for Clinical Photography/Digital Imaging is completed and scanned into the health record for each patient.

          • Pursuant to the Health Care Department Operations Manual, Section 2.2.2, Use and Disclosure of Protected Health Information Based on Patient Authorization, in instances where release of HIV/AIDS status may be required to diagnose or treat a patient’s condition, written authorization from the patient is required on a CDCR 7385, Authorization for Release of Protected Health Information.

        • Verbal Consent: Designated health care staff shall request verbal consent prior to each encounter in which a digital image will be taken.  If the patient has a signed CDCR 7120 within their health record but then verbally declines at the time of the encounter or appointment, the verbal consent would supersede the written consent. Refusals shall be documented on the CDCR 7225, Refusal of Examination and/or Treatment.

      • To ensure consistency within a series of digital images, the following steps shall be followed:

        • The date and time shall be pre-set on the digital camera so that the correct timestamp is recorded when the image is taken. State issued cell phones have the date and time automatically preset by the carrier.

        • The preferred background color is white (an under pad, pillowcase, towel, or sheet may be used) but solid; neutral colors are acceptable; blue and green backgrounds shall be avoided.

        • Ensure correct lighting.

          • Whenever possible, take the digital image at the same time of day to help with lighting consistency.

          • Use as much natural light as possible and keep artificial light use to a minimum to avoid shadows and discoloration.

          • If evenly distributed lighting exists in the room, turn the flash off.  The use of a flash may obscure essential detail in the glare of moist surfaces or cause white out; however, the use of flash may help to eliminate shadows.  When necessary, take the digital image with and without flash to test for best image quality.

        • Remove the existing dressing(s), if present, and cleanse the affected area(s) as ordered.

          • Place a fresh chux pad beneath the anatomic area to be photographed.

        • Position the patient.

          • If possible, the patient shall be photographed lying down, because some wounds/areas distort easily.

          • Where the patient’s body naturally curves, such as wounds/areas extending around a limb or heel, photograph such wounds in a “relaxed” position and then again with the assistance of other designated health care staff.

        • Prepare the wound measuring ruler by labeling it with the following:

          • Patient’s name;

          • Date of birth;

          • CDCR number;

          • Current date; and

          • Anatomic site being evaluated. Sites must be labeled consistently with the identification of the area within the health record.

        • Place the ruler in the field of view and position the digital device perpendicular (90-degree angle) to the wound/area at a distance of one to three feet.

          • Any subsequent photographic recordings shall be taken with the patient and digital device in the same position.

        • Focus the camera.

        • Consideration must be given at all times to protect the patient’s physical appearance within the digital image itself.

          • Care must be taken to respect the dignity, ethnicity, and religious beliefs of the patient.

          • The patient’s modesty must also be maintained by ensuring minimal patient skin exposure.

          • Avoid identifying characteristics (e.g., full face in the digital image).

          • Digital images of the face may be necessary if that is the location of wound/area needed for dermatology review or for documentation of injury to the face.  Digital images shall only be taken to focus on the affected area.

        • Take the digital image.

          • Multiple digital images may be necessary to document detail, wound/area positioning, and involved body part.

          • Avoid including any staff hands in the image whenever possible.

          • Preview digital images taken to ensure they are at the proper angle, include all the pertinent information, and are clear and visible.  Retake if necessary.

    • Transmission and Destruction

      • All digital images shall be uploaded to the health record multimedia manager by the designated health care staff who took the photograph as soon as possible.

      • Digital images shall not be altered in any way using any software, except for making the size of the entire photo larger or smaller for printing purposes.

      • Digital images taken of patients shall be stored on the digital camera and/or state-issued cell phone only until they are uploaded to the health record multimedia manager.  Digital images intended for a consulting specialist shall be sent and received via Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic transmission.

      • Once the digital images have been uploaded and verified, all digital images shall be immediately deleted from the digital device by the designated health care staff who took the photograph. The digital image must be destroyed to ensure the data cannot be reconstructed and the digital image is rendered unusable or inaccessible, including any data back-ups once transfer of the digital image is complete. No other copies shall be made or transferred to any other location.

      • Digital images shall be removed from the device before it is available for re-use. Regardless of the final intended destination, internal or external to CCHCS, the device shall not contain residual representation of any data that would allow re-construction.

      • If a device is found to contain digital images from previous documentation, staff shall ensure the digital images were appropriately documented in the patient’s health record prior to destruction. The SRN II or Physician Manager shall be notified and ensure proper training is provided to designated health care staff responsible for obtaining digital images.

      • Digital images may be transferred via the Health Information Exchange only when necessary to ensure consulting providers or specialists can evaluate progression of wound or disease in which the patient is being evaluated to provide appropriate treatment recommendations.

      • Digital images may be used as part of the peer review or disciplinary process in instances where a patient’s health care was delayed or deficient, or instances where the digital image was used, copied, transferred, or disclosed in any manner that violates HIPAA.

      • Digital images are subject to re-disclosure, if the patient has consented in writing for those images.

    • Training

      • Training and competency validation in clinical photography and safe storage of digital images shall be provided by the SRN II or Physician Manager to designated health care staff prior to use.

      • Competency in clinical photography shall be validated annually.  Validation may include direct observation, review of digital images taken by designated health care staff, or other validation methods to ensure competence.

      • Designated health care staff shall read all digital device instructions prior to use.

  • References

    • Federal Agencies Digital Guidelines Initiative Glossary
      http://www.digitizationguidelines.gov/term.php?term=digitalimage

    • Law Insider
      https://www.lawinsider.com/dictionary/medical-assessment

    • California Office of Health Information Integrity, California’s Statewide Health Information Policy Manual, Chapter 3, Section 3.2.2, Device and Media Controls

    • Department Operations Manual, Chapter 5, Adult Custody and Security, Article 2, Use of Force

    • Health Care Department Operations Manual, Chapter 2, Article 2, Section 2.2.2, Use and Disclosure of Protected Health Information Based on Patient Authorization

  • Revision History

    • Effective: 12/2021