Documentation : Photographic Documentation

Reasons for Photo Documentation of Evidence

The reasons for documenting evidence using high-quality photography include:

Review

• Photographs can be reviewed, even magnified, after the examination to confirm findings and determine if previously unnoticed findings are present.
• Photographs serve to enhance report writing and testimony by refreshing the examiner’s memory of specific findings.
• Photographic findings can be discussed among colleagues and consultants or can be compared with recently published data.
• Photographs allow improved communication for peer review with other child abuse physicians as a mechanism of education and accountability.
• Photographs of lesions can be compared, even overlaid with implements, if the magnification is precisely known and an appropriate ruler, such as an ABFO No.2 forensic ruler, is included in the photograph of the implement and the injury (https://arrowheadforensics.com/blog/proper-use-of-abfo-scales/).

Clinical diagnosis, education, and improvement

• Documentation of a normal examination may help to reassure the child or adolescent and their caregivers.
• Imaging during a first visit will allow comparison with findings during a follow-up or subsequent visit, such as serial photos of an injury that show the progression of healing.
• Photographs allow peer review and quality control. It is recommended that new examiners photograph all genital examinations and other findings suspicious for sexual abuse for adequate training and peer review. The National Children’s Alliance’s Standards for Accreditation of Child Advocacy Centers has specific requirements for peer review in cases of child sexual abuse (https://www.nationalchildrensalliance.org/ncas-standards-for-accredited-members/).
• Digital images can be transmitted electronically to colleagues for discussion. The use of telemedicine communication has emerged as a powerful tool in child abuse consultation and education.
• Digital video recordings and images may be a valuable tool for the education of learners of all professions, as well as for patient education of the child and their caregiver.

Reduction in number of examinations

Carefully acquired photographs and/or videos may save the child from the trauma of a repeat examination should a second opinion be requested of a particular child’s findings.

Legal evidence and testimony

• Still photographs and videos may be useful in court to illustrate significant findings for the judge and jury. Initial and follow-up photos of a child with failure to thrive can be powerful evidence in court.
• In some cases, a drawing or diagram may suffice and be as effective or more effective, avoiding the need for a sensitive photo to be shared in court. If a photo is subpoenaed and there is not a reason for its use, the examiner may ask the attorney to make a motion quash the evidence.

Photographic Equipment

There are several proprietary systems available for photographic documentation. Decisions on what system to use should be based on cost, quality of images, ease of use and ease of storage. At a minimum, whatever system is used, whether proprietary or simply a still or video camera on a tripod with attached light source, the essential component is image quality. The examiner should decide whether the still or video will more adequately represent the findings of interest. This decision may be most dependent on operator training and experience. If the examiner has both set-ups and can offer a choice between video versus still photos, the patient’s preference could also play a role in the decision.

No matter the equipment used, no photos should be deleted, and all photos must be managed as part of the medical record. If they are not directly transferred to the EMR, a secure system must be in place for transfer and storage with sufficient, redundant backup.

Digital Photography

Digital photography has completely supplanted film photography for forensic documentation of child abuse. The equipment can include one of a variety of available digital still cameras such as DSLRs, mirrorless cameras, digital video cameras and photocolposcopy systems. Digital technology produces images that can be stored easily and printed when needed. However, for legal reasons, take care to avoid changing the image in any way.

The quality of cell phone photos continues to improve and cell phone photography has emerged as a convenient way to photograph significant findings. The same principles of photo documentation apply when using a cell phone. Using an app such as Haiku, the images can be directly transmitted to the electronic medical record. Because cell phone lenses are not covered, they should always be cleaned just before photographing.

Video Documentation

Video recordings provide several advantages over still photography when documenting anal and genital findings:

• The dynamic variability of anogenital anatomy can be documented with greater ease than with a still camera.
• The examination can be recorded in its entirety for future reference.
• Video recordings can be made available for opposing expert review, thus saving the child a repeat examination.
• Video recordings are of course also available for consultation and peer review.

Use of a Monitor During Examinations with Photo documentation

• Viewing the findings on a monitor, rather than through an eyepiece on the colposcope, allows the examiner to maintain visual contact with the child and quickly respond to the child.
• A potentially unanticipated advantage of the monitor is a reduction in anxiety for many children who can view the examination along with the examiner.

Consent and Cooperation

In New York State, parent or guardian permission for taking photographs should be sought but is not required once suspected child abuse has been reported to the State Central Register. Document the consent or refusal in the medical record. Send the photographs to Child Protective Services when the report is sent or as soon after as possible; New York State Social Services Law ~ Section 416, https://codes.findlaw.com/ny/social-services-law/sos-sect-416/. See below for information on the release of photographs.

Children and families should be prepared for the photo documentation by the examiner or another healthcare provider on the medical team. Some hospital and other clinical settings obtain consent prior to the examination along with other consents for treatment. In some cases, children and families may be provided the opportunity to “opt out.”

Inform the child/adolescent of the need for pictures and engage him/her in the process. In some cases, photographing the physical or sexual abuse findings may cause physical or emotional discomfort for the child/adolescent. Be sensitive to this possibility and be able to explain why such documentation is needed. Young children will often cooperate if they are allowed to help with the process. With older children, having them see and, in some cases, handle the camera can ease their anxiety. Also, if the exam is being displayed on a monitor, such as in the case of most sexual abuse exams, anxiety can sometimes be eased by allowing the child to look at the monitor.

Very young children may not hold still for photographs. To obtain accurate photographs, it may be necessary to have an assistant or two distract the child. Having the young child sit on a caregivers or an assistant’s lap sometimes helps. With older children, it is usually possible to have them move to enable clear photographs from different angles. With young children, and particularly infants, the photographer must be the one to move.

In some cases, the child or adolescent may refuse to have photographs taken. Do not take photographs when an adolescent refuses, when a child does not provide assent or is exhibiting a significant behavioral response that prevents a good examination. If photos are necessary and a child is reacting negatively, consider whether it may be possible to reschedule an examination to a later date.

If the patient or family is uncomfortable with the taking of photos, the examiner needs to respect their decision given each individual case and need for documentation. Note that pictures are used mainly for forensic evidence and only occasionally impact medical care. Some concerns to consider regarding refusal of consent for photographs include:

• A concern that taking of genital photographs may normalize the experience.
• The patient may have had photographs taken during their abuse.
• In some cases, taking photographs might give the patient the impression that the examiner doubts their account of the abuse. For example, an older adolescent who discloses fondling or some other incident of sexual abuse where there is not an expectation for a physical finding, may feel invalidated or confused by a request for photographs.

Release of Photographs

Photographs are part of the medical chart. As such, they are legal documents subject to the same guidelines that govern the storage and release of other medical records. Medical and other facilities involved in child abuse evaluations should have a protocol in place for the release of photographs. Proper request, either by subpoena or other means, and signatures of receipt should be the minimal requirements for releasing photographs to an investigative agency.

Taking Good Photographs

The principles of photography in child abuse include proper planning, good equipment, adequate lighting, and planned composition:

• Whatever camera is used, it is important to set the camera to its highest resolution and lowest compression to obtain the best photos.
• Good lighting is crucial. It may be helpful to use a flash. Setting the flash to bounce off a wall rather than strike the skin directly may help. If using a flash overexposes or washes out the image, take photos with and without a flash.
• Because of variations in lighting and display modalities, photos should not be relied on to identify the true color of a lesion. If color identification is important, documentation should occur in the written report. Note, bruise color analysis to determine age of a lesion is often inaccurate.
• If possible, avoid background clutter in the photograph.
• Compose the picture the way you normally look at the area.
• Take photographs so that the surface that is to be photographed is parallel to the camera sensor and at the same level.
• Still cameras can be set to “center spot focus” so that only the lesion of interest is in focus. It is possible to center the focus on a cell phone camera by touching the screen where the lesion is.
• The first picture should include the patient’s name, date of birth and date of examination. This can be combined with a photo of the child’s face, or the face photo can be separate.
• Very young children may not hold still for photographs. Having an assistant or two distract the child or having the child sit on an assistant’s lap sometimes helps.
• Take at least 3 photos of a finding: distance to show the finding in relation to neighboring anatomy, close-up to show the finding in detail, and finally with an added ruler.
• Document pattern or circumferential injuries, such as burns and bite marks, by showing multiple views.
• If it is difficult to photograph lesions adequately with a single still image or when the injuries are extensive, consider using a video camera, burst shooting or video on a still camera.
• When using video, it is important to move the camera slowly so the scene does not appear “scrubbed.”
• Use close-ups to document pattern injuries and marks of restraint or bondage so that these injuries might later be compared with the rope or object that made the marks.
• Take close-up photographs of hands and fingernails to show damage to the nails, missing nails, or traces of blood, skin, or hair.
• Photograph transfer evidence that may be present on the body or clothing, such as dirt, gravel, or vegetation.
• It is always better to take more photos rather than fewer.
• Use the date stamp and captions, if available, to help track photos.