photos video and audio capture storage disposal … · web viewthis procedure outlines the...

CHHS17/265

Canberra Hospital and Health ServicesOperational Procedure Photo, Video and Audio: Capture, Storage, Disposal and UseContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Recording Devices..................................................................................................3

Section 2 – Consent...................................................................................................................3

Section 3 – Capture and Use.....................................................................................................4

Capture................................................................................................................................. 4

Use........................................................................................................................................5

Section 4 – Storage and Disposal..............................................................................................5

Storage..................................................................................................................................5

Disposal of unwanted images and audio...............................................................................6

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................6

References................................................................................................................................ 7

Definition of Terms...................................................................................................................7

Search Terms............................................................................................................................ 8

Attachments..............................................................................................................................8

Attachment 1: CRIS Help sheet - Importing eNotes and Images...........................................9

Doc Number Version Issued Review Date Area Responsible PageCHHS17/265 1 07/11/2017 01/07/2021 QGR - CSQU 1 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

This procedure outlines the processes that support staff to respect consumers and their privacy when taking, using, storing and disposing of images and audio for clinical and non-clinical purposes. This process includes the gaining of informed consent for these purposes.

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Alerts

Any images taken of a health consumer is considered a Health Record by the Health Records (Privacy and Access) Act 1997. Images and audio must be taken only with appropriate consent, and must be captured, used, stored and disposed of in accordance with the Act.

Images and audio of consumers may not be taken without informed consent of the consumer, and may only be captured by ACT Health devices or approved personal devices (see Mobile Communication Devices: Management and Use Policy and Procedure for further information).


Scope

This procedure applies to all staff within Canberra Hospital and Health Services (CHHS) who are involved in the capture, storage, disposal and use of images and audio of consumers. This includes students on placement and contractors working for CHHS.

This relates to all images and audio recorded for clinical purposes for the management and support of a consumer’s care including: Monitoring progress or effectiveness of treatment e.g. wound management Contributing additional diagnostic and/or treatment information in conjunction with

other procedures (eg. video monitoring for sleep studies or EEG) Seeking second opinions or advice from peers or experts (including all members of

multidisciplinary team) Assisting with consumer Identification.

Also in scope are images and audio recorded for the following non-clinical purposes: Quality Improvement Research Education and training Patient/family use.

It does not relate to:



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Medical/ diagnostic imaging (see definition of terms) where the image is the only source of diagnosis, or is essential for performing the test e.g. x-rays, CT scans, Cardiac Catherisation Laboratory images etc

Security cameras (staff are to refer to the ACT Health Closed Circuit Television (CCTV) Policy and Procedure and Data Release Policy for guidance on this issue)

Images and audio taken for marketing and promotional purposes Images and audio taken for forensic purposes Images and audio of staff or consumers taken by consumers Images taken for client home modification purposes.


Section 1 – Recording Devices

ACT Health approved recording devices/cameras must be used for capturing of images and audio. Personal mobile devices or phones should not be used unless approved as per the Mobile Communication Devices: Management and Use Policy and Procedure.


Section 2 – Consent

The consumer must provide their informed consent prior to any images and audio being captured, and this should be documented on the Consent for Photographs, Videos or Voice Recordings form on the Clinical Forms Register. Refer to Consent and Treatment Policy for further details on informed consent. Where informed consent is not provided, staff must not proceed with capturing images and audio.

Staff must:a. Explain the purpose for taking the images and audio, how they will be used, stored and

disposed of, andb. Obtain written consent from consumer or appropriate substitute decision maker and

place in the confidential clinical record.

Note: For images and audio taken to aid in the identification of a consumer, or images for patient/family use, only verbal consent (documented in clinical record) is required. Verbal consent should be documented in the clinical record including date and time of discussion and purpose of photos.

Note: For images taken specifically for research purposes, the Consent for Photographs, Videos or Voice Recordings form does not need to be filled out, as long as the consumer has signed a



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valid informed consent form (which has been approved by the ACT Health Human Research Ethics Committee) to participate in the research, which includes image capture.

For written consent, the following information should be recorded in the clinical record (the Consent for Photographs, Videos or Voice Recordings form on the Clinical Forms Register should be used): Date and time when taken Staff present (acting as photographer) Parents, guardian or carer present if appropriate Device used to capture the photos, videos or audio and type of photos, videos or audio

taken Number of images captured/length of video recorded. If the photos, videos or audio are deemed inappropriate and as a result will not be used

it should be noted in the clinical record that the images were captured and destroyed. Description of the images captured – i.e. anatomical location.

It is only necessary to complete one consent form for each episode of care. For example, ongoing wound monitoring under the same episode of care and referral would not require multiple consent forms. It is possible for the patient to withdraw their consent at any time, and this should be documented in the clinical record including date and time of withdrawal, and staff member present.


Section 3 – Capture and Use

CaptureCultural considerations and the consumer’s modesty must also be taken into account when capturing images and audio. Images and audio should only include areas/information documented in the consent

form Where intimate body parts (such as the breast, genital or rectal areas) are captured but

are not required within the scope of the audio/image capture, then these areas should be blurred or blacked out if possible

If a consumer has not consented to being identified in an image, any identifying features or marks (eg face, tattoos or birth marks) must be blurred or blacked out if possible prior to the image being saved as per section on storage and disposal. Alternatively, a different form of recording (eg. voice recording only) should be considered if appropriate

If it is not possible to de-identify the images (e.g. for video recordings), the consumer should be made aware of this and this should be documented on the consent form.

Use Once informed consent is gained, images and audio must only be used for the

purpose as outlined in the consent process and on the consent form.



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Images and audio captured for one of the above purposes may only be used, released or shared in accordance with the Clinical Records- Release or Sharing of Clinical Records of Personal Health Information Procedure. Images and audio captured on an ACT Government device or approved personal device may only be transmitted to other ACT Government devices or approved personal devices to members of the treating team. Capturing screen dumps of clinical information systems or using mobile phones or other portable devices to take digital photos of clinical record documents is not permitted.


Section 4 – Storage and Disposal

Images and audio captured for clinical care purposes are considered as part of the clinical record and are to be managed in accordance with the Clinical Records Management Policy and the Health Records (Privacy and Access) Act 1997.

Storage Images should be stored within the consumer’s clinical record where possible, ideally by

directly importing the digital image into the scanned clinical record following the Importing e-Notes and Images into CRIS factsheet (Attachment 1) (contact Clinical Records on 6244 2124 for authorisation to import photos/images into CRIS).

Where digital images are printed as hard copy and then added to the record and scanned into CRIS, image quality will be degraded (for optimal image quality preservation, direct electronic import to CRIS is recommended).

Videos and audio files cannot be stored within the CRIS record due to file incompatibility issues. Staff intending to capture videos or audio for clinical purposes are responsible for ensuring that a secure trackable storage system for this media is available prior to capture. A note should be made in the clinical record as to where the file is to be saved.

Images and audio must be deleted from the device used to capture them once they have been stored within the consumer’s clinical record.

If editing of a digital image is required (eg to de-identify consumer), the original should be destroyed, and only the edited version should be saved to the clinical record.

When images and audio are captured for non-clinical purposes, these recordings do not need to be kept in the clinical record. However the clinical record must document that the images and audio were captured, and must contain the consent form or record of verbal consent.

Images and audio captured for non-clinical purposes should be stored appropriately within the relevant administrative record e.g. if taken for education and training purposes, stored within the education and training records, if taken for research purposes, stored within the research record.

Disposal of unwanted images and audio Digital images and audio must be deleted from the device used to capture them once the

images and audio have been stored in the clinical record



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Destruction of unwanted hard copies should be by shredder/incineration; ideally in the work area (this can include secure recycling bins).


Implementation

Information contained in this procedure will be disseminated to staff through Divisional Executive Directors and appropriate line managers.


Related Policies, Procedures, Guidelines and Legislation

Policies Mobile Communication Devices Management and Use Policy ACTPS- Use of Recording Devices Policy Clinical Records Management Policy Consent and Treatment Policy Information and Communication Technology Resources – Acceptable Use ACT Health Closed Circuit Television (CCTV) Policy Data Release Policy

Procedures Mobile Communication Devices- Management and Use Procedure Mobile Communication Devices – Private use of Government- owned Devices Procedure Mobile Communication Device Requests Procedure Clinical Records- Release or Sharing of Clinical Records or Personal Health Information

Procedure Closed Circuit Television (CCTV) Procedure Perinatal Loss – Clinical and Bereavement Digital Images

Legislation Health Records (Privacy and Access) Act 1997 Privacy Act 1988 Territory Records Act 2002 Mental Health Act 2015

Standards National Safety and Quality in Health Services Standard 1 – Governance


References



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1. Bhangoo, Maconochie, Batrick, Henry (2005) Clinicians taking pictures – a survey of current practice in emergency departments and proposed recommendations of best practice. Emergency Medicine Journal 22: 761-765

2. Mahar, Foley, Sheed-Finck, Baker (2013) Legal considerations of consent and privacy in the context of clinical photography in Australian medical practice. Medical Journal of Australia 198: 48-49


Definition of Terms

Diagnostic Images Any images taken as part of the diagnosis or monitoring of a consumer’s treatment, eg X-rays, MRIs.

Identifiable Image Any photos or videos where the consumer is identifiable.

Images and audioAny photographs, video or audio recorded of a consumer while under the care of the Health Directorate. This includes photographs, video and audio taken with (but not limited to) the following: Video camera, Mobile phone (iPhone, Android devices etc), Tablet (iPad, Android devices etc), Cameras.

Images not for medical imaging purposesAny photos, videos or audio taken for educational purposes and/or for clinical purposes such as: Education and training Emailing peers for second opinions/advice Monitoring Quality Improvement Research

Only approved devices should be used to capture photos, video and audio. Personal devices can be used once approved under the Mobile Communication Devices: Management and Use SOP.

Informed ConsentA person gives consent based upon an appreciation and understanding of the facts and implications of an action. The person must be given the relevant information and have the capacity to understand it.

Medical/Diagnostic ImagingDoc Number Version Issued Review Date Area Responsible PageCHHS17/265 1 07/11/2017 01/07/2021 QGR - CSQU 7 of 10


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Medical imaging is the technique and process used to create images of the human body for clinical purposes. It includes diagnostic imaging, interventional radiology and nuclear medicine services.

Non-Identifiable Image Any photos or videos where the consumers identifiable features (eg. faces, tattoos, birth marks) are blurred or blacked out.


Search Terms

Photo, Video, Audio, Recording, Mobile, Recording Device.


Attachments

Attachment 1: CRIS Help sheet – Importing eNotes and Images

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



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Attachment 1: CRIS Help sheet - Importing eNotes and Images



CHHS17/265



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