B6. Photo-Documentation

These recommendations are for pediatric examiners related to photo-documentation during the examination.

Be aware that photo-documentation during the medical forensic examination is the standard of care in prepubescent child sexual abuse cases. In every case, examiners should take diagnostic quality still images or videos of detected injuries as well as normal, apparently uninjured anatomy. Note, however, that photographic images are not a substitute for detailed written documentation of exam findings (Adams et al., 2015).

Recognize that pediatric examiners—not law enforcement or child protective service investigators—should take these photographs during the examination, for several reasons: (1) Photographs taken during the medical forensic examination become part of the child’s medical record. (2) Photographs taken during the examination are highly personal in nature. As with adult and adolescent patients,^[1]  If photographs of the child are taken by nonmedical personnel, images taken should include only the child’s head and extremities and not the torso or anogenital region. Examiners are encouraged to seek training on photography techniques and procedures to use with child victims of sexual abuse.

Explain medical photography procedures to children and caregivers. The explanation should be developmentally appropriate for children, and linguistically appropriate for children and caregivers. Taking photographic images of children in the aftermath of sexual abuse can be traumatizing, especially if photography was a component of the abuse. In these cases, children might not be able to discern the difference between photography used in the sexual abuse and forensic photography. To help avoid traumatization and facilitate decision making, examiners should explain to children and caregivers: the purpose of the photography during medical forensic care; the extent to which photographs will be taken and the procedures that will be used; how photographs will be securely stored at the health care facility and to whom they can be released; potential uses of photographs during investigation and prosecution (especially anogenital images); and the possible need to obtain additional photographs following the examination. Explaining the process and welcoming questions helps to reduce reluctance to photo-documentation during the examination. In addition to being comfortable explaining this information to children and caregivers, examiners also should also be comfortable discussing sexual abuse that included still- and video-imaging, if that issue arises during the medical history or in the course of the examination.

Respect patient choices about photography. Consent to take photographs during the examination should be sought, as a component of the informed consent process. (See B1. Consent for Care) If children do not assent to all or any part of photography, their choices must be honored. Note that if children or parents/guardians are hesitant or decline photography, it may be due to cultural beliefs and practices—anogenital imaging, in particular, may be highly embarrassing and unacceptable. For example, certain religious communities have strong mandates about exposure or imaging of the body in public or in a non-private arena. Children may also be reluctant to be photographed during the examination if photography comprised a component of the abuse. It can be useful in these instances to explore with the child and caregiver whether procedure modifications may make photography acceptable, while respecting their cultural practices and mandates. If modifications are not acceptable, the written record may have to suffice as exam documentation. Regardless whether photography is used, examiners should document examination findings on body mapping forms and diagrams.

Maintain the child’s privacy. Strive to minimize the child’s discomfort while being photographed. Drape children appropriately while taking photographs. Children differ in what will help them be more comfortable while being photographed: For those for whom it is developmentally appropriate, examiners can offer the opportunity to explore the photo-documentation equipment prior to its use, view images taken, and even to watch the examination if video-colposcopy is utilized (Ricci, 2011). It may be helpful for a caregiver and/or other supportive person to provide comfort for the child. (See B7. Examination)

Consider the photographic equipment. Examiners should be familiar with photographic equipment operation and be prepared to use it during the examination (e.g., camera supplies and instructions should be available and the equipment should be clean and in working order). If questions exist regarding what type of equipment to use, it may be helpful to consult with a professional photographer, outlining the type of photographs that will be taken. Alternatively, consult with other local examiner programs as they often have knowledge about photographic equipment used in these cases and the effectiveness in capturing images during the examination. Generally, any good-quality photographic equipment may be used as long as it can be focused for undistorted, close-up photographs and provide an accurate color rendition (California Office of Emergency Services, 2001).

Take initial and follow-up photographs as appropriate in a case, according to facility policy. See below for basic photography principles. In addition to initial photographs taken in the course of the medical forensic examination, photography may be repeated as evolving injury or healing on patients’ bodies occurs following the examination (e.g., bruising may appear days later). Create procedures that examiners, investigators, multidisciplinary response teams, and caregivers can follow to ensure that post-exam changes are documented. In addition to documenting evolving injury or healing, follow-up photographs can clarify findings of stable, normal variants in anatomy and nonspecific findings, like redness or swelling, that could be potentially be confused with acute injuries.

Establish health care facility policies for storage, retention, and controlled release of photo-documentation in these cases. Secure storage and restricted access to photo-documentation is critical in general, but particularly important in small communities where exam facility employees may be acquaintances, friends, and family members of patients and/or suspects. The facility legal and risk management departments are sources for consultation regarding photo-documentation annotation, handling, storage, retention, and release practices.

Photographic images taken during the medical forensic examination should be considered part of the patient’s medical record maintained by the health care facility. As mentioned earlier, examiners should not include photographic images in the evidentiary kit sent to the crime lab.

Facility policy should clarify how photo-documentation in these cases will be securely stored. Examiners should coordinate with facility information technology security, compliance, and legal departments to ensure compliance with privacy laws, rules, and regulations for storage of electronic records and images. 

Health care facility policy should allow release of photo-documentation only in certain situations to certain entities, as legally allowable, in order to prevent misinterpretation and misuse.^[4] Such policies should include mechanisms that allow examiners and/or medical records departments, in concert with facility legal counsel or risk management, to evaluate in each case whether release of the requested images is legally allowable and/or could be potentially harmful to the patient (Botash, 2009). Other health care providers treating the child typically do not need access to photographic images taken during the examination. Photographic images should not automatically be turned over to investigating agencies or the multidisciplinary response team. Instead, investigators or the investigating team should be guided by body maps and diagrams used in documentation in deciding which photographs to request. When photographs are released, the release should be done in a manner that limits the chance of misinterpretation by nonmedical professionals. One approach is that, prior to release, an examiner could review images with recipients so they understand what is significant about the findings. 

Facility retention policies for photo-documentation and other medical records must take into account the need for access to these records in criminal and civil proceedings. These records must be retained indefinitely to accommodate cases of delayed reporting, delayed processing of evidentiary kits, CODIS hits, cold case investigations, conditions that extend the statute of limitations, and the appeals process. With this in mind, facility policies for medical forensic record retention should be based on justice standards rather than traditional medical record keeping, storage, retention, and destruction policies.^[5] Medical records in these cases should not be destroyed. (See B4. Written Documentation)