5520.pdf - LSU HEALTH CARE SERVICES DIVISION BATON ROUGE...

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Unformatted text preview: LSU HEALTH CARE SERVICES DIVISION BATON ROUGE, LOUISIANA POLICY NUMBER: 5520-12 CATEGORY: Medical Services CONTENT: Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors and Workforce Members EFFECTIVE DATE: September 20. 2012 REVIEW DATE: REVIEW DATE: INQUIRIES TO: Michael Kaiser. Chief Medical Officer LSU HCSD, Medical 533 Bolivar Street. Room 362 New Orleans. Louisiana 701 12 Tel hone: 504-568-2259 Facsimile: 504-568-2090 Ilfl‘r I?- lnterim Chief Executive Officer Date LSU Health Care Services Division ' ) / ‘ a / 92? fl 5?\ Dep y Chief Executive Officer Date LSU Health Care Servic on Chief Medical Officer Date LSU Health Care Services Division Photographing, Video Recording, Audio Recording, and Other Imaging of Patients, Visitors and Workforce Members Purpose To establish guidelines for situations where patients and/or workforce members may or may not be photographed, video or audio recorded or otherwise imaged within the facility. To facilitate compliance with the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164, and any and all other Federal regulations and interpretive guidelines pertinent to the Act’s enforcement. Policy The facility must take reasonable steps to protect patients, visitors, and workforce members from unauthorized photography, video or audio recordings, or other images. Due to the sensitive nature of patient information and to protect patient privacy, the facility must follow the guidelines and procedures outlined below before allowing, or prior to, photographing, video or audio recording, or otherwise imaging patients, visitors or workforce members. The Joint Commission Standards prohibit unauthorized recordings, films, or other images of patients made for external use. The taking and use of unauthorized photography, video or audio recording, or other images not only is a violation of federal regulations and The Joint Commission Standards, it is morally and ethically wrong. It is not acceptable for LSU HCSD hospital facility employees to use their own photographic equipment to take photographs of patients, particularly using camera phones. Telephone image systems are not specifically intended for medical use, and this can have medico-legal implications for practitioners. For purposes of this policy, when authorization or consent is required it may be obtained from the patient or the patient’s legal representative, as defined by State law. (Reference LSU HSCD Policy 5501, Informed Consent for Medical Services) It is not sufficient to rely on the photographer’s (patient, workforce member, visitor) judgement that a particular patient is unlikely to be identified from a particular photograph; consent must be obtained for all photographs, unless the image is truly anonymous. It is sometimes possible for people to be identified from faceless photographs, e.g. those showing a tattoo, birthmark or other distinguishing mark. Sanctions will be applied in accordance with the facility’s discipline or conduct policy and LSU HCSD Policy 7527, Mitigation after Improper PHI Use or Disclosure. Definitions For the purpose of this policy, the following definitions shall apply: Audio Recording- refers to recording an individual’s voice using video recording (e. g., video cameras, cellular telephones), tape recorders, or other technologies capable of capturing audio. 2 5520-12 Authorization- refers to a written form executed by the patient or the patient’s legal representative that meets the requirements in the Authorization for Uses and Disclosures of Protected Health Information. (Reference-LSU HCSD Policy 7501, Use and Disclosure of Protected Health Information that Requires an Individual’s Written Authorization.) Authorizations must be obtained for uses and/or disclosures of protected health information that are not for treatment, payment, or health care operations purposes or are not otherwise permitted by the HIPAA Privacy Rule. Consent- refers to the patient’s or patient’s legal representative’s written acknowledgment of and/or agreement to the use and/or disclosure of protected health information for treatment, payment, or health care operations purposes or other reasons permitted by the HIPAA Privacy Rule. (These purposes are generally communicated to patients through the Notice of Privacy Practices and specifically communicated to patients through face to face encounters and documented in the medical record.) Patient- refers to either the patient or his/her properly designated representative if the patient does not have capacity. I Patient Identifiable Photographs/Images—defined in Attachment A of this policy. Photography— refers to recording an individual’s likeness (e. g., image, picture) using photography (e.g., cameras, cellular telephones), video recording (e. g., video cameras, cellular telephones), digital imaging (e. g., digital cameras, web cameras), or other technologies capable of capturing an image (e. g., Skype). This does not include medical imaging such as MRIs, CTs, laparoscopic images, etc., images of specimens, images of present on admission (POA) or acquired wounds, i.e. pressure ulcers, or surgical wounds. Visitor-An individual on hospital premises who is not a patient or workforce member. Workforce Member- refers to employees, volunteers, trainees, and other persons whose conduct, in the performance of work for the facility, is under the direct control of the facility, Whether or not they are paid by the facility. Procedure This section describes the limited circumstances in which photography and/or audio recording may be used to capture or record a patient’s likeness or voice. Worldorce members must only use designated company-owned devices to photograph or audio record a patient. Departments possessing a company-owned device must have procedures in place to address how the devices will be securely stored, how photographs or recordings will be saved, stored, and disposed of, and designate appropriate personnel with access to the devices. Photographs must not be stored on the device (e. g., camera) or on unencrypted memory cards and must be timely deleted (e.g., within 24 hours) from the device. The use 01 personal cellular telephones, cameras, etc. is strictly prohibited. 3 5520—12 l. Photographing/Audio Recording of Patients or Visitors within the Facility by Workforce Members for Personal Use: Workforce members are prohibited from photographing or audio recording patients or visitors within the facility for personal use. This includes, but is not limited to, taking pictures to share with friends and/or co-workers, to post on the internet using social media (e. g., Facebook, MySpace, and Twitter), etc. 2. Photographing/Video or Audio Recording Patients by Patients, Family Members, and/or by Visitors: The facility is not required to obtain consent from the patient when the patient is the subject of the photography/audio recording and such recording is performed by the patient or the patient’s family members or the patient’s visitors. To the extent a workforce member is aware of any inappropriate attempt to photograph a patient the workforce member must take reasonable steps to ensure that patients are not photographed within the facility by a patient or the patient’s family members or visitors. 3. Photographingflideo or Audio Recording Workforce Members by Patients, Family Members, and/or by Visitors: Patients, family members, and/or visitors are not permitted to take photographs of or audio record workforce members without consent. To the extent a workforce member is aware of any inappropriate attempt to photograph a workforce member the workforce member must take reasonable steps to ensure that workforce members are not photographed within the facility by a patient or the patient’s family members or Visitors. 4. Photographing/Video or Audio Recording Patients by Workforce Members for Treatment Pgrposes: Some images, unless associated with other unique details (e.g. birth mark, tattoo, scar), do not identify patients, i.e. they are intrinsically anonymous when presented alone. (See Photography definition on Page 3.) If photographic or electronic reproduction shows the full face or comparable image of the patient or any of the identifiers listed in Attachment A (See Attachment A of this policy), written patient informed consent (See Attachment B of this policy), is required before workforce members may photograph or audio record a patient for patient care purposes. A patient’s image may not be altered in any way to achieve anonymity and so avoid the need for consent. Blacking out of the eyes in a facial photograph is not an acceptable means of anonymizing the image. 5. Photographing/Video or Audio Recording Workforce Members by Workforce Members: Workforce members are not permitted to take photographs of or audio record other workforce members without consent. To the extent a workforce member is aware of any inappropriate attempt to photograph or audio record a workforce member the workforce member must take reasonable steps to ensure that workforce members are not photographed or audio recorded within the facility by another workforce member. 4 5520-12 Photographing Patients by Workforce Members for Security or Health Care Operations Purposes: In some care areas, the conditions of admission for specialty units may advise patients that photographs or video recordings may be taken for security or health care operations purposes (e.g. Photos taken for inclusion in inpatient psychiatric patient charts for identification purposes and elopement precautions. This does not apply to general security surveillance of public areas. 7. Photographing Patients by Workforce Members to Document Abuse or Neglect: When a State Agency responds to a report of suspected abuse and/or neglect, the LSU HCSD facility will cooperate with the investigating officers. However, prior to any photographs being taken by workforce members, such actions must be reported to and coordinated by the LSU HCSD Legal Department. In general, patient consent is not required; however, the photographs may not be used for any other purpose beyond submission to the investigating agency unless otherwise permitted by federal or state law (e. g., for treatment purposes). Reference-LSU HCSD Policy 4528, Investigations) 8. Photographing Patients by Workforce Members for Educational/Training Pupposes: When a photograph of a patient is taken for the intended use in lectures/training activities within the LSU HCSD facilities, the photographs must be taken with a facility owned camera. Personal cellular telephones, cameras, etc. must not be used. If the photograph will include any of the identifiers listed in Attachment A (See Attachment A of this policy), the photo must be de-identified prior to display in educational/training presentations. Written consent must be obtained from the patient. The patient should understand the purpose of the photograph, who will see it, whether copies will be made, the arrangements for storage and how long it will be kept. 9. Photographing/Audio Recording Patients by Workforce Members for Research: Any use and/or disclosure of photographs or audio recordings for research purposes will be in compliance with state and federal regulations concerning privacy and research. If a photograph or audio recording is determined to be identifiable, the medical school’s Institutional Review Board overseeing the specific research project will determine if additional authorizations are required based on the criteria set forth in the privacy laws. (Reference—LSU HSCD Policy 7520, Use and Disclosure of PHI for Research.) 10. Photographing/Audio Recording Patients by Workforce Members for Publicity Pugposes: Facilities must obtain written authorization from the patient prior to photographing/audio recording the patient for publicity purposes, e.g. marketing materials or media releases. The authorization is only good for the type of photographs/recordings indicated and the timeframe listed in the authorization. Otherwise, a new authorization form must be obtained. When the photography/audio recording is for marketing purposes, the facility must obtain an “Authorization for Use and Disclosure of PHI for Marketing Purposes” (Reference-LSU HCSD Policy 7517, Use and Disclosure of PHI for Marketing Purposes.) 5 5520-12 ll. 12. 13. 14. When the photography/audio recording is for news media and/or public information, the facility or HCSD must obtain a “Permission for Public Information and/or Photographs” form. (Reference—LSU HCSD Policy 9501, Communications-Public Information Policy, Protocols for News Media and Public Information.) Photographing/Audio Recording Patients by the Media or Law Enforcement: In general, facilities may permit news media or law enforcement agencies to photograph or audio record a patient if the patient’s responsible (e. g., attending) physician agrees the patient is medically stable and the patient consents. Requests from Media sources must be reported to and coordinated by the LSU HCSD Communications Director prior to the encounter with the patient or patient’s representative. Requests from law enforcement sources must be reported to and coordinated by the LSU HCSD Legal Department and the hospital specific police/security force. (Reference for Media-LSU HCSD Policy 9501, Protocols for News Media, Public Information, Emergencies and Reportable Incidents. Reference for Law Enforcement-LSU HCSD Policy 7501, Use and Disclosure of Protected Health Information for Payment, Treatment, and Health Care Operations, Attachment A; Louisiana R.S. 40:2113.4, C. (1), (2).) Photographing for Gifts or Commemorative Pupposes: In order for facilities to photograph a patient when the photograph will be given as a gift or sold to the patient or patient’s family, written consent must be obtained. When a vendor is used to provide these services, the facility must obtain a written authorization from the patient or the patient must initiate contact with the vendor. For example, the facility may leave a brochure about the services in the patient’s room in order for the patient to contact the vendor directly. (Example: Labor and Delivery (L&D) services using a vendor for infant photos.) Non-clinical Photography/Video Recording-Patients, patient’s family members, visitors and workforce members are prohibited from photographing and video recording the content on communication boards (ED Tracking screens, care area white boards), portions of medical records, patient labels on medical record binders, and any other such items bearing patient names and any other identifying information. Storage, Retention and Disposal of Images: A. All photographs which become part of the healthcare record should be immediately printed and securely fixed within the chronological clinical record. Care should be taken in so doing not to obliterate part of the photograph. B. Where consent has been obtained to take and store images for teaching purposes, research or publication, the clinical/faculty/staff member is responsible for making appropriate arrangements to secure and safeguard the material on the LSU HCSD hospital/facility network via the local Information Technology Department. 6 5520—12 The images must be converted into PDF format, and be stored with password protection on a secure file server. Such images of patients may only be stored for use in connection with approved and registered research projects or for the preparation of teaching materials. For later retrieval purposes, each image should be assigned a file name by which it can be clearly identified, preferably incorporating the patient’s hospital number and the date of photography. Under no circumstances should the name of the patient be used as the file name. In the case of photographic transparencies, a second copy should be made at the time of photography to be used as a master transparency. This will be returned to the LSU HCSD hospital/facility and must be securely stored in the originating department. Where it is impossible to obtain a master as well as a show copy, the original transparencies should be regarded as masters and duplicates made as necessary for further use, provided appropriate consent has been obtained. It is a good practice to maintain a log of such transparencies. If patient consent is withdrawn, all copies and the master image should be destroyed as far as possible, and only material that is part of the patient’s health record should be kept. Before leaving the employment of the LSU HCSD hospital/facility staff must erase any digital images of patients from the network unless specific permission to retain images for teaching purposes is obtained from the Medical Director. Such permission may be granted subject to the retention of copyright and all reproduction rights by the LSU HCSD hospital/facility, and only if proof can be provided that the patient has consented to such uses. C. Other images used to make treatment decisions must be printed for storage in the medical record. Exceptions: source data, interpreted or summarized in the patient’s medical record, for example: ECG tracings, pathology slides. Departments must refer to the LSU HCSD Policy 7529, Designated Record Set to determine which images must be stored in the medical record. D. Secure area(s) must be designated to store photographs and recordings that contain protected health information and will not be housed in the patient’s record. Photographs and recordings must be clearly identified and securely stored and readily accessible for retrieval. State law and the Record Retention Policy must be followed for retention of the records. (Reference-LSU HCSD Policy 0516, Record Retention.) E. In all cases, the original must be deleted from the camera’s memory as soon as possible 7 5520-12 15. Disclosure: Photographs and audio recordings should not be released without specific written authorization from the patient, unless the disclosure is for treatment, payment or health care operations purposes or is otherwise permitted or required by law. (Reference-LSU HCSD Policy 7513, Use and Disclosure of Protected Health Information for Treatment, Payment, and Health Care Operations) Unless prohibited by law, photographs and audio recordings may be released to the patient in accordance with Patients’ Right to Access. (Reference-LSU HCSD Policy 7503, Patient’s Right of Access to and Obtain a Copy of Their PHI) Facilities must retain the originals in accordance with state law and the Records Management Policy. (Reference-LSU HCSD Policy 0516, Record Retention.) Roles and Responsibilities Hospital Administrator: - will undertake a survey of existing photographic/audio equipment within the LSU HCSD hospital/facility to determine availability to the workforce. - will insure there is adequate equipment to meet the needs of the clinical workforce. Medical Director: - is responsible for ensuring the members of the medical staff are aware of and comply with this policy. Academic Chiefs/Faculty Physicians: -are responsible for ensuring the interns, residents, and fellows are aware of and comply with this policy. Nurse Managers and Heads of Departments: -All nurse managers and heads of departments who are responsible for areas involved in taking photographs and/or video recordings are responsible for ensuring their staff are aware of and comply with this policy. Designated Custodians: For each location of photographic/video equipment there must be a designated employee to be responsible for: 0 Storage and security of the photography/video/audio equipment 0 Ensuring the equipment is in good working order 0 Ensuring that images are printed as soon as possible after being taken, (or uploaded to secure file server for storage and not retained on the camera) 0 Maintaining a supply of consent for...
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