EFFECTIVE DATE: 10/05 / PAGE 1 OF 3
APPROVED BY: / LAST REVIEW DATE: 10/05
SUBJECT: PHOTOGRAPHING OF PATIENTS FOR EDUCATIONAL/PEFORMANCE IMPROVEMENT PURPOSES / REVISION DATE: DRAFT 10/25/05
PURPOSE In compliance with Texas law and with the Health Insurance Portability and Accountability Act’s (HIPAA) privacy rules, CHRISTUS Santa Rosa Health Care (CSRHC) has adopted the following policy and procedures regarding photographing patients for educational or performance improvement purposes.
POLICY CSRHC shall obtain the written consent of patient or legally authorized patient representative
for photography of any procedure, care or treatment provided to or for the patient for educa-
tional or performance improvement purposes. For definition purposes, photographs or photo-
graphy include film, digital image, and video. Consents for photographs obtained for research
projects are documented through the research informed consent process. The dignity and
modesty of the patient is considered at all times by CSRHC when photography is used, and
the photography must be limited to specific areas identified by the physician for the educational
or performance improvement purpose identified.
PROCEDURES
1. The patient’s physician is required to provide information to the patient or legally authorized representative regarding any photography and the use of the photography for educational or performance improvement purposes and provides documentation of such in the patient’s medical record.
2. The written consent of the patient or legal representative is obtained on the Consent for Photography/Videotaping for Educational or Performance Improvement Purposes (form #0039859) by the caregiver. The authorization given for photography remains valid throughout the hospitalization or outpatient visit unless and until the patient or his or her legal representative withdraws or restricts the authorization.
3. The patient’s signature should be witnessed by a competent adult, preferably a CSRHC Associate, and the witness’ signature must be included on the authorization form.
4. The consent form is placed in the patient’s medical record with the NCR copy sent to the Quality Management Department.
5. A new authorization form should be signed for each new series of photographs during each hospitalization or outpatient visit.
6. Patient or legal representative has the right to request cessation of photography by notifying the caregiver or the Patient Representative.
7. Patient or legal representative has the right to rescind consent for the use of the photographs for either educational and/or performance improvement by notifying CSRHC Administration in writing prior to the end of the hospitalization or outpatient visit.
8. Patient or legal representative also has the right to withdraw consent for use of photography by notifying CSRHC Administration in writing not longer than 30 days after filming is completed.
9. All CSRHC Associates are bound by signing the Confidentiality Statement to protect the patient’s identity and confidential information
10. Any non-CSRHC Associate involved in photographing patients is required to sign a confidentiality agreement to protect the patient’s identity and confidential information. A confidentiality agreement can be obtained through the CSRHC Intranet.
RESPONSIBLE POSITION: Director, Physician Services
HISTORY: New Policy
REFERENCES: CHRISTUS Health Management Directive 004, Guidelines for Release of Patient Information to the News Media.
For policy on news media photography, see Policy #CO-PM-04-2, Release of Information to News Media.
SAMPLE CONSENT FOR PHOTOGRAPHY/ VIDEOTAPING FOR EDUCATIONAL OR PERFORMANCE IMPROVEMENT PURPOSES
I understand that by signing below, I am giving consent for educational and/or performance improvement photographs to be made of me. Photographs include film, digital image, and video. It has been explained to me that CHRISTUS Santa Rosa Health Care will consider my dignity and modesty at all times when photographing my body and that the photographs will only be made of the specific areas of my body for which I have given consent. I further understand that my refusal to have photographs made of me will in no way effect my care.
I understand that CHRISTUS Santa Rosa Health Care will retain the ownership rights to my photographs.
I understand that I have the right to request cessation of recording or filming by notifying my caregiver or the Patient Representative. (Patient Representative can be reached by calling the hospital operator at “0”.)
I understand that I have the right to rescind consent for use of my photographs by notifying hospital CSRHC Administration in writing prior to the end of the hospitalization or outpatient visit. I also understand that I have the right to withdraw consent for use of photography by notifying CSRHC Administration in writing not longer than 30 days after filming is completed.
EDUCATIONAL OR PERFORMANCE IMPROVEMENT PHOTOGRAPHS. I understand that:
1. Educational photographs are photographs used for teaching and publication purposes;
2. Performance Improvement photographs are those used for hospital-sponsored improvement initiatives.
3. My identity will not be published in any manner or form without my explicit additional written consent; and
4. Educational/performance improvement photographs will be stored in a secure manner to protect my privacy and identity.
By signing this Consent, I confirm that this Consent has been explained to me in terms that I understand, that I have had an opportunity to ask questions, and that all of my questions have been answered to my satisfaction.
I, the undersigned, hereby agree to photography of ______for educational or performance improvement (circle one or both) purposes.
Patient/Legal Representative
Signature: ______Date:______
Printed Name: ______
Relationship, if not signed by Patient: ______
Witness: ______Date: ______
NCR Copy of Consent Form is to be submitted to Quality Management Department.
Form # 0039859 (Rev 10/05)