FAQ: Photography for pressure ulcer documentation:
The NPUAP neither recommends nor discourages the use of photography for
pressure ulcer documentation. However, if photography is to be used, the
NPUAP strongly advises that explicit protocols be established for each institution
or home health agency and that these protocols be followed consistently.
Photography is potentially useful either at the time of admission to document the
status of the skin or as an adjunct to treatment documentation. Each purpose
has advantages and disadvantages, and each presents challenges for the
administration and staff.
Admission Photography
When photography is used at the time of admission, the underlying rationale is
to demonstrate the presence of pressure ulcers at the onset of care.
1.
2.
3.
11P56
Advantages
Photography adds a visual
confirmation to the written record.
Demonstration of a wound
imported to the facility mitigates
liability concerns.
Protocols for photography further
ensure that all body surfaces at
risk of skin breakdown are viewed
during the admission exam.
1.
2.
3.
Disadvantages
Equipment used only on admission
invites inconsistent application and
undermines adherence to standard
procedures.
Deep tissue injury may not be
evident on admission and the
initial photographs may not
capture the full extent or severity
of the damaged tissue.
A photograph taken at a single
point in time may undermine faith
in the treatment plan if the
condition worsens.
Documentation Photography
Photography used as an adjunct to ongoing treatment provides a visual record to
enhance documentation, but there are further issues that may arise:
1.
2.
3.
Advantages
Photography may offer a more
1.
accurate means for assessment of
wound dimensions and wound base
characteristics over time.
Rates of healing, and therefore
measures of therapeutic efficacy,
are more readily appreciated when
the data are held in a visual format.
A serial, visual record verifies staff
2.
attention to the problem and
mitigates liability concerns
3.
Disadvantages
Serial photography as a means
for measuring pressure ulcer
healing and to assess the
efficacy of therapy requires a
higher level of technological
accuracy, and therefore, up-front
costs for the equipment and ongoing costs for data storage.
The demand for consistency
underscores the need for staff
training and credentialing.
Photographs of large pressure
ulcers can be inflammatory in a
jury trial despite compliance with
all reasonable standards.
Other Issues
Technical challenges are also different for the different applications. An
admission photograph needs only to be able to visualize the skin surfaces, and
there is greater flexibility in format, e.g. Polaroid® or regular photographic film,
or digital photography (see below). The NPUAP strongly encourages that the
protocol includes a means for patient identification, date and time marking and a
sample measure (e.g. a 10 cm strip of paper tape) in each frame, and that the
photographs become part of the medical record.
Photographic standards for serial measurements used to document ongoing care
needs to be more stringent. The NPUAP strongly recommends digital
photography with a density of at least 1.5 megapixels, while >3 megapixels is
preferable and offers the best ratio of picture clarity versus the cost of
equipment. These protocols should include explicit criteria that standardize the
equipment, aperture settings, distance from the wound and field of view, as well
as a means for patient identification, date and time marking, and a sample
measure in the frame of the picture. The use of a computer program for
planography is another option to improve the accuracy of the photographic
record and to objectively assess healing over time. Implementation of any
program should include in-service training with demonstrated competencies and
periodic studies of inter- and intra-rater consistency.
Digital photography, videos and tele-medicine technology offers the additional
capability of sharing the images with the attending physician, surgical
consultants and wound care colleagues to better assess the current state of the
wound, its progress towards healing and to develop plans for future
interventions. Sharing photographs via e-mail requires special security provisions
to assure compliance with HIPAA regulations.
Although digital photography is preferred in most clinical circumstances, the ease
with which the image can be manipulated renders this form of documentation
inadmissible in many court cases. Therefore, if photography is to be used solely
at the time of admission, a more permanent format is recommended.
References:
The articles below relate to the use of Polaroid® or regular photographic film and
offer suggestions for protocol development applicable to all forms of
photographic documentation:
Houghton PE. Kincaid CB. Campbell KE. Woodbury MG. Keast DH.
Photographic assessment of the appearance of chronic pressure and leg
ulcers. Ostomy Wound Management. 46(4):20-6, 28-30, 2000 Apr.
Krainski, M. Photography in nursing. AJN/September, 1998. 98(9), 16BB.
Hood CA, Hope T and Dove P. Videos, Photographs and Patient Consent.
BMJ. 1998;316:1009-1011
Campbell C. and Sacremento L. Photodocumentation Reverses Medicare
Reimbursement Denial. Ostomy/Wound Management. 1995;3(41):18-23.
Louis DT. Photographing Pressure Ulcers to Enhance Documentation.
Decubitus. 1992;5(7):38-45.
Kutcher J and Arnell I. Documentation of Skin Using Photography.
Ostomy/Wound Management. 1992;Nov/Dec,38:23-28.
Pieper B, Miklos C, Mance B and Adams W. Nurses Documentation About
Pressure Ulcers. Decubitus. 1990;3(1):32-34.
Tele-Medicine references:
Halstead LS. Dang T. Elrod M. Convit RJ. Rosen MJ. Woods S.
Teleassessment compared with live assessment of pressure ulcers in a
wound clinic: a pilot study. Advances in Skin & Wound Care. 16(2):91-6,
2003 Mar-Apr.
Kodza L, Scheurich A. The impact of telemedicine on outcomes of chronic
wounds in the home care setting. Ost/Wound Manag 2000;46(10):48–53.
Wirthlin D, et al.Telemedicine in vascularsurgery: Feasibility of digital
imaging for remote management of wounds. J Vasc Surg June
1998;1089–100.
Special thanks to the following who contributed to the development of this FAQ
response:
Laurie Rappl
Pat Boynton
Ben Pierce