Some EMRs include the ability to upload clinical photographs from a mobile device directly into your patient records. This feature allows you to document a diagnosis, treatment or an unusual finding.

Posted in Risk Management on Wednesday, June 27, 2018

Some EMRs include the ability to upload clinical photographs from a mobile device directly into your patient records. This feature allows you to document a diagnosis, treatment or an unusual finding. 

If you elect to use this EMR function, consider having a policy so that risks are minimized and it’s used consistently across your team. Even if your EMR only lets you scan in clinical photography, a policy is a good idea.

Clinical photography, as part of the healthcare record, should be afforded the same degree of privacy, security and confidentiality as other healthcare records. Therefore, take care when using this mode of documentation.

When creating a clinical photography policy, consider addressing:

• Who is authorized to take photos (e.g., physicians or nonphysician practitioners)
• What devices may be used (e.g., only clinic-owned devices using those apps associated with the EMR and on secure devices)
• When (if) using cell phones, which phones may be used (only those with appropriate firewalls, encryption and owned by your practice?)
• When using devices with memory cards, care should be taken to:
  • Ensure device is physically secure at all times
  • Remove the memory card at the end of each patient visit
  • Download the photograph(s) to a secure (encrypted) server
  • Erase the memory card 
  • Consider setting up a user log for devices that might be shared
• Approved purposes for uploaded images (e.g., treatment, research, education)
• Areas of the body permitted to be photographed
• Guidelines for uploading photographs—incorporate a final review and approval of the photo by the healthcare provider
• Patient consent that is obtained prior to each photograph and a form (reduces “he said/she said” scenarios) that:
  • Identifies the content of the image 
  • Indicates why the image is being taken 
  • Confirms the patient’s understanding and agreement to proceed with the photograph

The American Health Information Management Association provides a sample policy with procedures to get you started on your own clinical photography policy. 

Remember, when it comes to creating policies and procedures for your practice, it is important to consult legal counsel about local and federal regulations. Additionally, your policy manual should be a living document that is reviewed annually and revised as necessary.