Participant Materials
Nursing Responses to Elder Mistreatment
Participant Materials
10. Photo-Documentation in Elder Mistreatment Cases
Purpose
Photo-documentation of physical trauma in elder mistreatment cases can supplement written documentation in the patient medical record and related evidentiary reports. Photographic images can often give life to the patient history and findings from an elder mistreatment assessment.[1] Nurses should be aware of their facility policies related to photo-documentation, as well as related local and state criminal justice system procedures. Specifically, they should know and be able to carry out their roles in taking and documenting photographic images or facilitating the taking of these images by other medical staff. This module discusses the purposes of forensic photo-documentation, related nursing roles and basic techniques.
Learning Objectives
By the end of this module, participants will be able to:
· Discuss purposes of photo-documentation in elder mistreatment cases;
· Describe nursing roles in photo-documentation; and
· Discuss how to photograph findings in elder mistreatment cases using basic forensic techniques and document photographic images on body maps.
Case Study Introduction
Case study
Mrs. Simpson is an 87-year-old resident of a local nursing home. She has no known relatives. She is transported to the neurology clinic of a local university health center by ambulance for a follow-up visit for a stroke she suffered three months ago. The stroke left her mostly paralyzed and with mild speech impairment (she can understand others but her speech is slow and slurred). She is able to eat very slowly with assistance. On exam, she is found to have bruising bilaterally under her chin, bruising to her upper and lower gum lines, and a tear to the frenulum of her lower lip. She has a series of dime-sized circular reddish-blue bruises to both upper inner aspects of her arms. There is a 3-by-4 inch, Stage 3 pressure ulcer on her right posterior hip. She is accompanied by a nursing assistant who states that, as far as she knows, the patient is in her normal state of health and she has no idea how she got bruised. The nursing assistant said that her records indicate the pressure ulcer has been there since she was admitted to the nursing home from the hospital after the stroke. The nurse and physician have concerns that the patient is being force-fed, otherwise abused and neglected. When the nurse asked the patient how she got the injuries on her face and arms, she said that another nurse assistant was sometimes rough with her and got mad when she didn’t want to eat or took too long to eat. The patient said that the nurse assistant also got mad when she couldn’t understand what she was saying. If the nurse assistant was angry at her, she would ignore her for the rest of her shift. The patient is admitted to the health center for a further work-up and APS is notified.
Questions to consider:
? Do you think photographic images are necessary in this case? Why? What specific images would you document?
? What are your practice setting procedures for taking forensic photographic images in elder mistreatment cases? Who can photograph? What type of camera is used? How would your procedures play out in this case?
? Is patient consent needed to take photographic images in this case? How might it be obtained?
? Does photo-documentation become part of the health record? If not, where are they stored?
Key Points
The purpose of forensic photo-documentation in elder mistreatment cases is to supplement but not replace written documentation. Often photographic images can give life to the patient history and findings from an elder mistreatment assessment.[2]
Recognize that photographic images become part of the patient medical record. They also may become part of evidentiary reports (e.g., a completed sexual assault evidence collection kit). These images need to be maintained and stored in a confidential manner, as with other health records and reports. Photographic images may not be released without HIPAA authorization from the patient or guardian, unless state statutes indicate otherwise or pursuant to a court order. With the proper releases or court orders, photographic images can be presented in court as evidence.
Identify procedures for photo-documentation and who should take photographs. Every health care facility needs policies and procedures to determine how photographs are to be taken and by whom, as well as how to store photographs and copy digital images. Will the nurse or other medical personnel (e.g., a forensic nurse examiner or medical forensic photographer) be responsible for photography? If other medical personnel take photographs, what are the procedures for contacting them and getting their assistance? Where is the camera, can it be easily accessed and how is it operated? What documentation of photographs is needed? Nurses need to be aware of and able to carry out these policies and procedures.
Know the extent of photographs that will be useful. Health care facility policy should guide medical personnel in the extent of photographs that should be taken in known and suspected mistreatment cases. Jurisdictions take different approaches; law enforcement officers and/or prosecutors should inform health care facilities as to what photographs they view as critical in these cases. In some facilities, photographs are routinely taken, with patient permission, of both detected injuries and normal (apparently uninjured) anatomy involved in the assault. Other facilities limit photographs to detected injuries.[3]
Be aware of the type of camera used and how to operate it. Most health facilities have or are moving toward the use of digital cameras for photo-documentation (replacing 35 mm cameras) because of their availability, affordability, and ease of use, labeling, storing and retrieval of digital images.
Get patient consent to photograph. Explain to patients and/or their guardians why the medical staff would like to take photographs, procedures to take and store photographs, and potential uses of the photographs. A signed consent by patients/their guardians is required to take photographs.[4]
Consider patient comfort and privacy. Minimize patients’ discomfort while they are being photographed and respect their need for modesty and privacy. Drape them appropriately while taking photographs.
Forensic Photography Basic Techniques
Key Points
Achieve an accurate representation of a wound. Getting an accurate/true representation will require that nurses work with features of their cameras such as lighting/flash, shutter speed and focusing.
Obtain a true and accurate image of what was seen. Nurses need to know that they may be called to testify that an image is a true and accurate representation of what they assessed and treated on a particular day at a particular time. Digital cameras are useful tools in getting true/accurate images since images can be immediately viewed and retaken if necessary.
Be familiar with camera functions that control lighting. The accuracy of an image can be affected by lighting. Use adequate lighting whether the source is natural, flood lights or flash. Avoid bright backgrounds. Keep in mind that use of flashes and lighting in the exam room can change the color of evidence. Document any alterations to the environment to enhance photos.
A measurement scale should be used in photographs to help quantify the approximate size of an injury. If a scale is used in an image and part of the body is covered by the scale, another image of that area of the body should be taken without using a scale. A variety of images can be used as photographic scales, such as rulers, coins and pencils.
Photographs should be taken using a forensic photography technique called “rule of thirds.” Whenever wounds are photographed, do the following: Start with a front-facing, full body photograph of patients. Then take photographs of the injured area from three distances: six feet (farthest distance); four feet (middle); and two feet (close-up).
Label photographic images. Be consistent in how you label images across cases. The following should be clear for each photographic image:
· Patient name, ID number and date of birth;
· Facility name;
· Date and time photograph was taken;
· Name of person taking the photograph;
· Location of the wound; and
· Case number (if law enforcement has assigned one).
Most software for digital cameras permits words to be superimposed directly onto the image. Make sure the words do not obscure the wound or any aspects of the image that may explain the cause of the wound. To limit the words on an image, you can include patient information in the first and last photo taken to ensure accurate case identification. Then each photo can just include the location of the wound and a patient identifier.
If and when photographic images of wounds are printed, NEVER write directly on the back or the front of the prints. Ink from pens can smear (“bleed”) and obscure the image. In addition, writing on photographs with pencils or ball point pens will leave indentations on the prints.
If information is not imposed on an image using computer software, one of the most effective ways to label printed photographs is with 2” X 4” shipping labels. Labels can be written by hand or printed on a laser or ink jet printer.
Photographic documentation in medical record: Digital images can be labeled, burned onto a non-rewriteable CD-ROM, stored in the medical record and then printed as needed. Alternately, images can be printed multiples to a page and placed in the record along with the CD-ROM.
· Medical photographs can be combined with medical records by printing digital images on a blank facility progress form or taping photographs on facility progress forms.
· Health care providers should take their own photographs and not rely on law enforcement photographs.
Timing of photography: When possible, take pictures of wounds prior to medical treatment, as well as after the wounds are cleaned and treated. When there is physical evidence, photograph the evidence where it was found on the body and/or clothing, before it is removed. Also, take follow-up photographs as needed if there is ongoing care and contact.
Body Mapping
Examples of body mapping forms that can be found online:
California Clinical Forensic Medical Training Center. Forensic medical reports: Elder/dependent adult abuse and neglect medical evidentiary examination (2004), Acute adult/adolescent sexual assault examination (2002), Sexual assault suspect examination (2004), Suspicious injury report (2003) and Domestic violence medical/evidentiary examination (2004). Sacramento, CA: California Emergency Management Agency. Retrieved from http://www.ucdmc.ucdavis.edu/medtrng/ and http://www.ccfmtc.org/forensic.asp.
South Wales Adult Protection Forum. (2006). VA1(a) Body Map (example of body map form in APS report). UK: Author. Retrieved from http://www.newport.gov.uk/stellent/groups/public/documents/form/cont286448.pdf.
Key Point
Use of body maps. While pictures of wounds can “speak a thousand words,” sometimes photographs in elder mistreatment cases are so graphic a judge may not allow them into trial so as to not unduly bias a jury against the accused. Therefore, every time nurses take photographic images of patients, they should also mark the location of each injury photographed on a pre-printed body map/diagram, as well as the type and size of the injury.
Also, use body maps to document accurate bruise coloring on a photograph or mark locations of tenderness that may not be visible in a photograph.
10 Photo-Documentation Page 6
[1] Blue Cross Blue Shield of Michigan, Blue Care Network, Michigan Coalition Against Domestic and Sexual Violence, Michigan Nurses Association, Michigan Osteopathic Association, Michigan State Medical Society, Wayne State University Institute of Gerontology, Wayne County Prosecutor’s Office and Metro Health Foundation, Reach out, intervening in domestic violence and abuse: The health care provider’s reference guide to partner and elder abuse (Detroit, MI: Blue Cross Blue Shield of Michigan, 2007), http://www.bcbsm.com/pdf/DV_ReferenceGuide.pdf.
[2] Blue Cross Blue Shield of Michigan.
[3] Office on Violence Against Women, A national protocol for sexual assault medical forensic examinations, adults/adolescents (Washington, DC: U.S. Department of Justice, 2004), 85.
[4] This and above sentence from P. Gray-Vickrey, Recognizing elder abuse, Nursing. FindArticles.com. (1999), http://findarticles.com/p/articles/mi_qa3689/is_199909/ai_n8871345/pg_2/?tag=content;col1.