When and how should I add a medical result photo to a patient's record?

Guidelines for Adding Medical Result Photos to Patient Records

Medical result photos should be added to patient records with proper informed consent that explicitly outlines all intended uses of the images, with special consideration for patient privacy and confidentiality. 1

Consent Requirements

Adult Patients (18+ years)

• Obtain written informed consent from the patient before taking any medical photographs
• Clearly explain all potential uses of the image:
  • Medical record documentation
  • Teaching/educational purposes
  • Publication/research
  • Electronic distribution 1, 2

Special Populations

• Children ages 7-18: Obtain both parental/guardian permission AND child's assent
• Children under 7: Obtain parental/guardian permission only
• Patients with developmental disabilities: Obtain guardian permission and patient assent when possible
• For fetal death/stillbirth: Obtain parental consent 1

Documentation Process

1. Use HIPAA-compliant methods only:

   • Secure EHR-integrated photography apps specifically designed for clinical documentation 2, 3
   • Avoid standard camera apps, text messaging, or non-encrypted email 2

2. When taking photos:

   • Show the patient the image before finalizing
   • Explain that once published, images cannot be fully retracted
   • Document in the chart that consent was obtained 1

3. Storage considerations:

   • Attach photos directly to the electronic medical record
   • Never store medical photos on personal devices
   • Ensure proper encryption of all digital files 2

Patient Rights and Protections

• Provide patients with a copy of the consent form
• Include contact information for withdrawing consent later
• Explicitly state that refusing photography will not affect medical care
• Remove images from display if consent is withdrawn (except for already published print media) 1

Common Pitfalls to Avoid

• Inadequate consent: Research shows many patients (nearly 50%) don't realize written permission is needed for identifiable photos, while 88-89% of healthcare professionals recognize this requirement 4

• Insecure transmission: Never use standard social media platforms, public cloud storage, or non-encrypted email for medical photos 2

• Improper reuse: Patient acceptability for photo reuse decreases as audience size increases - 90% approve for one-on-one education but only 42% approve for social media educational use 3

• Lack of policy: Many departments lack written policies for clinical photography, leading to inconsistent practices and potential privacy violations 5

• Inadequate documentation of forensic images: When documenting injuries that may have legal implications, photos should be taken before treatment when possible, with proper attention to technical quality 6

By following these guidelines, healthcare providers can appropriately document medical findings with photographs while protecting patient privacy and maintaining proper ethical standards.