In some fields of practice, such as dermatology, photographs are a common way to document a patient's condition and response to treatment. These records are no different from narrative records — the photo is meant to document what is necessary to achieve an adequate medical record and should be considered part of that record.
Many of the photographs will be smaller than 8½ x 11; the practice should either tape them to a full-sized sheet of paper or keep them a plastic slip cover, says TMA's Managing Your Medical Records. The photo should have identifying data on the reverse side.
Photos that contain sensitive anatomy should be safeguarded (as every single page of every medical record should be safeguarded).
Many surgeons make videos of surgeries, particularly surgeries performed via scopic equipment such as arthroscopy or laparoscopy. The practice should have a means (digital, disk, or both) to file and catalog the videos. Because the videos are a part of the medical record, a backup system is mandatory.
Some surgeons provide copies of the video to the patient. They should do this only pursuant to a practice-wide policy, developed in consultation with legal counsel and the medical liability insurer.
If you have questions about medical records, check TMA's Medical Records webpage for legal white papers, tips, and more. Or, contact the TMA Knowledge Center at (800) 880-7955 or knowledge[at]texmed[dot]org.
Published Jan.21, 2014
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Last Updated On
January 22, 2014