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KIDSta Protocol Section B 6
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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).

 

Photo-documentation provides a record of visual forensic evidence findings at the time of the examination, before they are disturbed or collected (Green, 2013). “A good photograph is tantamount to stopping the clock” (Green, 2013). Photographic images are useful for: reassuring the child and caregiver regarding physical findings; avoiding additional examinations to confirm findings; allowing for later reviews for diagnostic, testimony preparation, quality assurance, or continuing education purposes; and creating a baseline for comparison to findings from follow-up visits or if other suspicions arise (Botash, 2009; Ricci, 2011).

 

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).

 

Forensic photograph equipment can include many types of digital cameras or other still or video image capturing devices with magnification capabilities. Technological advances offer continuously new options for digital imaging. Advantages of digital imaging equipment is cost effectiveness, applicability for other patient care issues, and the quality of the image that can be obtained with a basic digital camera (Green, 2013). Digital single lens reflex (SLR) products offer setting options, such as image sensors and manual and automatic exposure settings, and should have at least 12 pixels for forensic evidentiary purposes (Staggs, 2014).

 

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.

 

Basic Photographic Principles[2]

· Patient identification. Link patients’ identifying information to each photographic image, according to jurisdictional and facility policy. For example, include patient name, date, and time as the first image. Follow jurisdictional policy for whether to include an image of the child’s face with this identifying information.[3] For identification purposes, this information should book end the digital images taken during the examination of this patient (at beginning and end of images). Digital imaging can automatically embed the date/time, camera settings, and a variety of other technical data in each image. This data can be accessed when images are downloaded onto the computer. A digital image log that records each image’s file number, with a description of the image, may be included as part of the patient care record.

· Clear and accurate photographs. Images taken that do not provide a clear and accurate depiction should be deleted. Note that this practice reflects a medical standard, as appropriate for pediatric examiners, rather than an investigative standard.

o The examiner should strive to control every element in the photographic image to produce a clear, accurate representation of the injury or anatomy.

o Assure adequate lighting, exposure, and that the image is in sharp focus.

· Standard. Use a standard or ruler for size reference in photographs, in addition to those photographs that identify patients and anatomical locations being photographed.

· Take photographs of the child prior to the collection of forensic specimens and medical interventions, such as cleaning or suturing, when possible. Do not alter or move forensic evidence before or during photographing.

· Orientation of shots. Take at least three shots at different distances from the body:

o In some jurisdictions, a full body photograph is taken as an identification photo. It may also be appropriate to show scope of injury or state of clothing. When taking full body photographs, ensure as much modesty and privacy for the patient as possible, through draping and other techniques. Photographs taken solely for the purpose of identification should be done with patients fully clothed or in a gown.

o Take an overview image of the injury’s location, including anatomic landmarks for orientation of the injury.

o Take medium-range photographs of each injury, providing a wide enough view to identify the specific anatomical site being photographed (e.g., a photograph of a left forearm laceration at medium range would contain the left hand and left elbow of the patient, as well as the injury itself).

o Take close-up images of injuries, with and without the standard. The goal of the close-up images should be to capture subtleties in texture and color and any pattern injuries that may be observed.

· Photographing skin. Close-up photographs of hands and fingernails may show traces of blood, skin, or hair. Look for damage to nails or missing nails. Photograph marks of restraint or bondage around wrists, ankles, or neck; they may be compared later with an object in question that made the marks. Photograph transfer evidence present on the body or clothing, such as dirt, gravel, or vegetation.

· Bite mark evidence. Photograph bite marks, according to facility and jurisdictional policy. (See B8. Evidence Collection. Also see Riviello (2013))

 

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)

 

Contact staff at SAFEta.org to discuss specific issues related to establishing health care facility policies for storage, retention, and controlled release of photo-documentation in these cases.

 

It is helpful if exam facilities have policies and procedures related to digital imaging, including the following: procedures as part of medical forensic examination, image security and authorization for access, image enhancement details, duplication and release, storage, and a secure image back-up system. Digital images included in the medical record should be preserved in the original file format. If an image is to be enhanced, a new file should be created (original remains unchanged) and details of the enhancement recorded. The facility should make available, to those with legitimate access, image copies in an encrypted format.[6]




 Table of Contents B7. Examination


[1] See OVW (2013).

[2] These principles were adapted in part from Green (2013) and OVW (2013).

[3] Note the child’s face should never appear in photographic images where genitalia is exposed. However, facility policy may call for a separate photograph of the child’s face for identification. This image may be useful in cases where it is a long time before the child goes to court. The image of the child’s face can help to show the child as she/he was when the abuse occurred.

[4] One concern is that routine release of photographic images in these cases, often of children’s genitalia, to agencies that do not have strict methods in place for protection of these images can result in their release to people outside the investigative team, such as members of the press. Note that prosecution discovery obligations may require granting access to exam photographic images by defense/defense experts.

[5] This paragraph was adapted in part from AHIMA (2011).

[6] This information on the admissibility of digital imaging was adapted from Green (2013).

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