Clinical Photography Documentation Note

Date/Time of Photography: [Date and time of image capture] (Include range if prolonged; if images were imported, record original capture time if known.)

Location: [clinic / ED / inpatient / OR / bedside / procedural suite / telehealth / home setting / other]

Photographer: [Name], [Role: RN / MA / physician / medical photographer / other] (If unavailable at signing, enter "[Pending—requires completion before finalizing]".)

Ordering Clinician: [Name], [Role] (If same as photographer, state "same as photographer".)

Patient Verification: [Two-identifier verification: completed / not completed] ; [Anatomic site and laterality confirmation: confirmed / not applicable] (If unavailable at signing, enter "[Pending—requires completion before finalizing]".)

Clinical Indication

[Brief clinical reason tied to the patient's problem]. Purpose: [diagnosis/characterization / monitoring/serial comparison / consultation (store-and-forward) / pre-procedure documentation / post-procedure documentation / quality/safety documentation / clinical record and care coordination]. (If images are patient-provided, state this explicitly. Do not infer purpose—use the ordering clinician's stated purpose or default to "clinical record and care coordination" if unclear.)

Consent and Authorization

• Decision-making capacity: [Patient has capacity / Patient lacks capacity—legal decision-maker: [Name], [Relationship]]
• Consent status: [obtained / declined / deferred] (Required—never infer. If declined or deferred, include brief explanation.)
• Elements explained: [Body area(s) to be photographed], [Clinical purpose], [Storage location], [Who may access]
• Patient preferences or limitations: [Stated preferences, e.g., exclude face/identifying marks, limit angles] (Omit if none stated.)
• (Include only for sensitive area photography or when policy requires.) Chaperone: [offered and accepted—[Name], [Role] / offered and declined / not applicable / not available—[Rationale and mitigation]]
• Privacy measures: [Draping, limited exposure, private setting, minimal personnel, etc.]

(Include only if any non-clinical or external use is planned.)

• External Use Authorization: [Intended use(s): teaching / publication / marketing / research / other]. Written authorization signed: [yes—stored at [location in chart]]. Redisclosure risk and revocation process reviewed with patient.

Image Acquisition

• Image source: [Captured in facility by staff / Patient-provided / Consulting service / Other]
• Device/workflow: [Institution-approved device/app/workflow used: yes] (If exception: [Reason], [Secure transfer method], [Upload confirmed: yes/no], [Deletion from non-approved device confirmed: yes/no].)
• Standardization: [Patient position], [Camera distance], [Lighting], [Measurement scale: yes/no], [Color reference: yes/no] (Include when serial comparison is intended.)
• Identifiers in frame: [Face or unique identifiers included: yes/no]; [Rationale if included]; [Steps to minimize identifiers]

Image Inventory

(Do not leave blank if images exist. Add one entry per image or coherent image group.)

• [Body site with laterality]: [View: anterior / posterior / lateral / oblique / overview / close-up], [Timing: baseline / intra-procedure / post-procedure / hospital day # / follow-up], [Clinical target], [Count: # images]
• (If applicable) Standard [X]-view set per [Protocol name]—[Body site], [Timing], [Total count]

Storage and Chart Location

• Storage system: [EHR media module / PACS / Specialty image system / Scanned documents / Other]
• Chart path: [e.g., Media tab, Imaging → Photos, Scanned Documents → Clinical Photos]
• Identifiers: [Encounter ID], [Accession number], [Media ID], [Folder/album if applicable]
• Upload status: [Completed—images viewable / Pending—[Responsible party], [Expected completion]]
• Verification: [Verified / Cannot verify—task assigned to [Name/Role] with follow-up plan]

Care Team Sharing

(Include only if images were shared beyond routine chart availability. Omit entirely if no sharing occurred.)

• Recipient(s): [Name/Service and role]
• Method: [EHR-internal share / Approved secure messaging / Telehealth platform / Other approved method]
• Images shared: [All / Subset—describe which images]

Interpretation

(Optional—include only when images inform management, serial comparison is clinically relevant, or quality limitations may affect interpretation. Do not duplicate physical exam findings.)

[Brief description of what images demonstrate, salient findings, and any limitations]. (For serial comparison: "Compared with images from [date], [change described]." If using patient-provided images, state whether correlation with in-person exam occurred.)

Exceptions

(Include only when workflow deviated from standard practice. Omit entirely if none.)

• [Patient declined photography—brief reason if offered]
• [Partial consent—areas allowed vs excluded]
• [Technical failure—description and mitigation/next steps]
• [Urgent/emergent exception—rationale and safeguards]
• [Patient requests regarding copies or privacy—how addressed]

Attestation

Consent documentation completed. Storage/linking: [verified / pending—[responsible party and plan]]. (If applicable: External-use authorization documented and stored as noted above.)