Photography should be used to document injury, forensic nursing expert says

Long-term care providers should stop telling staff to avoid taking photos, and instead create policies to make such images part of a medical record, an expert said Friday.

Many providers fear photographs could ultimately be used against them in a lawsuit. But more often, the photos show both how an injury occurred and how it is healing, explained Daniel Sheridan, Ph.D., RN, FNE-A, FAAN, Texas A&M professor and Forensic Nursing Program Director.  

“It can show you the wound is healing, albeit it slowly,” he said. “Photos can be very protective. It is a standard of nursing.”

Sheridan spoke during two sessions on forensic nursing and its implications on injuries and abuse during the American Association of Directors of Nursing Services meeting in Baltimore.

For example, a resident who falls may have a bruise on her face, and as it heals, blood will travel down in ecchymosis spread, causing a discoloration of skin. That may mean the injury appears far worse days later to the family, and consistent photographs and documentation will protect the facility from claims of malfeasance. The Centers for Medicare & Medicaid Services recognizes that falls occasionally happen among the elderly, Sheridan reminded the group, and a photo(s) can make it clear what happened.

Once policies are in place, a nurse should always take a photo of the injury, Sheridan said.

“A nurse can say what it is,” he noted. “They should not take it as evidence, but as medical documentation of injury.”

Other best practices include using different lighting, and bracketing photos with details such as patient's name and date of birth. Nurses should first take a full photo of the patient, then a second photo four feet away, and then another two feet away. They should use a ruler with the injury or, in lieu of that, a sanitized coin to give context to the size of a circular-shaped wound.

A facility should have a designated camera or institutional cell phone, as staff should never use their personal cell phones, Sheridan emphasized. There should be clear guidelines on where the camera is kept, charging information and other relevant details.

With regards to consent for residents and photos, admission forms should say “We medically document injuries.” If a facility starts photographing as a new best practice, a letter to families can say, “Effective this date, we are going to start photographing and write to us by this date if you don't want that.”

Sheridan also advised on ways to improve documentation. Nurses should stop using color charts for bruises due to a lack of evidence that they work, and should use correct terminology related to cuts, lacerations, bruises and ecchymosis. He also advised on best practices in injury documentation, including how to make it clear a resident left a facility in good shape.

“When someone is heading out your door for a medical procedure or a weekend with the family, do a quick visual head-to-toe,” he said. “What did they leave with and what did they come back with?”

Nurses need better training on writing reports with objective statements, he said. For example, nurses should write they paged a physician at specific times, and the time he/she returned the page, rather than use phrasing such as “He finally returned my call at 12:30.”  

With patients, “make sure your staff is writing the behavior,” Sheridan said. They should avoid the words “refused, uncooperative or noncompliant.” They should use words such as “said, states, reports.” Train staff on the difference between witnessing a resident falling, and finding a resident on the ground, he said.

Biased language also can creep in related to abuse allegations. “They should never ever ever in the record use ‘alleged assault,'” Sheridan said. “You would never say ‘the patient alleges having diarrhea for three days.”

In incident reports, directors of nursing should use the names of staff members interviewed, or his or her initials. “Name the people with whom you are talking with. It's not accusatory,” he said.

Ultimately, all staff need to remember how documentation can help them. “If you didn't chart it, it didn't happen,” he reminded the crowd.