Photographs

Note: These photographic documentation recommendations are for specially trained medical forensic professionals. Photographs should be taken by the health care provider conducting the medical forensic assessment, respecting the dignity and privacy of the patient. “Taking photographs of patient’s anatomy that was involved in the assault should be part of the medical forensic examination process in sexual assault cases” (DoJ, 2013, p. 91).

Do not take photographs of the anogenital area unless you are a specially trained medical forensic professional. Any photos taken by non-medical professionals should include only the head and extremities (DoJ, 2016, p. 91).

Photographs taken during the medical forensic examination become part of the patient’s ‘medical record’ or per facility policy. Examiners are encouraged to seek training on photography techniques and procedures to use with patients who experienced sexual violence. Respect patients’ choices regarding photography. If the patient does not assent to all or any part of photography, their choices must be honored. (DoJ, 2016, p. 129-130).

• Recommendations from DoJ, 2013 (p. 91):
  • Consider the extent of forensic photography necessary.
  • Consider the equipment.
  • Be considerate of patient comfort and privacy.
  • Strive to minimize the patient’s discomfort while being photographed.
  • Explain forensic photography procedures to patients.
  • Take initial and follow-up photographs as appropriate, according to jurisdictional policy.

Basic photographic principles

• “Patient identification—Link patients’ identifying information to each photographic image, according to jurisdictional and facility policy. For example, include patient name, date, and time as the first image” (DoJ, 2016, p. 131).
• Clear and accurate photographs—Images taken that do not provide a clear and accurate depiction can be deleted.“Standard—Use a standard or ruler for size reference in photographs, in addition to those photographs that identify patients and anatomical locations being photographed” (DoJ, 2016, p. 131).
• Take photographs of the patient “prior to the collection of forensic specimens and medical interventions, such as cleaning or suturing, when possible. Do not alter or move forensic evidence before photographing” (DoJ, 2016, p. 131).
• “Orientation of shots. Take at least three shots at different distances from the body:
  • Take an overview image of the injury’s location, including anatomical landmarks for orientation of the injury.
  • Take medium-range photographs of each injury, providing a wide enough view to identify the specific anatomical site being photographed.
  • Take close-up images of injuries, with and without the standard. The goal of the close-up images should be to capture subtleties in texture and color and any pattern injuries that may be observed” (DoJ, 2016, p. 131).
• These are recommendations; not all patients will tolerate or consent to the above process.

Guidelines

• Informed consent must be obtained from adult patients prior to obtaining photographs.
• Informed consent from the adult parent/caregiver/guardian should be obtained for child patients.
• Assent from children for obtaining photographs is recommended.
• “A physician, dentist, or psychologist having reasonable grounds to believe a child’s physical or mental condition has been adversely affected by abuse or neglect may examine the child without the consent of the child, the child’s parents, or other person authorized to consent to treatment under this subchapter. An examination under this section may include x-rays, blood tests, photographs…”  (Texas Family Code §32.005).
• Patients have the right to know how photographs will be stored and utilized.
• Reassure patients that the photographs are for medical forensic purposes and are protected in medical facilities.
  • Photographs and use of camera devices must follow facility protocols and be maintained appropriately.
  • Do not use personal photography equipment/phones for taking photographs. Chain of custody and confidentiality of photographs cannot be maintained while using personal photography equipment.
  • Photographs may be sealed by court order at conclusion of the legal proceedings (Texas Code of Criminal Procedure §38.45).
  • “‘Covered entity’ means any person who: (A) for commercial, financial, or professional gain, monetary fees, or dues, or on a cooperative, nonprofit, or pro bono basis, engages, in whole or in part, and with real or constructive knowledge, in the practice of assembling, collecting, analyzing, using, evaluating, storing, or transmitting protected health information. The term includes a business associate, health care payer, governmental unit, information or computer management entity, school, health researcher, health care facility, clinic, health care provider or person who maintains an Internet site; (B) comes into possession of protected health information” (Texas Health and Safety Code §181.001).
• Photographs can be an important adjunct to the physical findings noted by the examiner on the body surface diagrams.
• Policies should be in place that outline the process for obtaining photographs, the method to be used to identify the patient in the photographs and the means to link the photographs to the permanent medical record for each patient.
• Photographs make it possible to obtain additional expert opinion of findings without requiring the patient to undergo additional assessments.
• Photographs are useful as part of a peer review process to help ensure competent medical forensic assessments.
• Photographs may be used in some legal proceedings to demonstrate physical findings.
• In children who experience recurrent sexual abuse, evaluation and comparison of findings is possible with good quality images (Botash, 2009).
• Photographs may be taken of normal findings, based on jurisdictional policies. In prepubescent patients, photo-documentation is considered a standard of care for both normal anatomy as well as for injuries (DoJ, 2016).
• Photograph or image management:
  • Anogenital photographs and images may not be routinely released to law enforcement.
  • Consider releasing anogenital photographs, images or videos only to prosecution with subpoena, after patient’s express written consent,
  • Ensure there are clear statements in health record regarding if photographs or images were taken.
• Additionally, Texas Government Code §420.032 states, “In a county with a population of three million or more, the forensic portion of a medical examination of a child reported  to be the victim of a sexual assault must include the production of photo-documentation unless the medical professional examining the child determines that good cause for refraining from producing photo-documentation exists. The photo-documentation must include images of the child’s anogenital area and any signs of injury apparent on the body of the child. If photo-documentation is not produced, the medical professional conducting the forensic portion of the medical examinations shall document in the child’s medical records the reason photo-documentation was not produced.”