Photo Identification in an Electronic Medical Record

Photo identification in Electronic Medical Record

Standardizing wound and ostomy photography for the Electronic Medical Record (EMR). Standardizing photo documentation was implemented when our outpatient wound center transitioned to the EMR enhancing clinical documentation. Weekly photo documentation has been used in the wound center which recently is being utilized on the inpatient case load. A standard, photo tag, is used for any wound or ostomy to identify patient using; initials, CSN record number and date. This photo tag also depicts the measurements of length, width, depth, undermining or tunneling, along with anatomical position. In the EMR, wound center pictures are available to be viewed during an inpatient stay. Our practice for photographing is placing a blue background to give contrast to wound and peri wound from surroundings, improving picture clarity and positioning. Increased visibility of anatomical location and measurements are achieved with photo tag and blue background.  Prior to this implementation, photographs varied person to person and left measurements and positioning in question. With EMR, photos are saved and uploaded directly following each outpatient and inpatient visit.  This method provides continuity of care in the facility spectrum from inpatient to outpatient clinic to home care.  With pictures available, communication of wound status with primary care or tertiary care provider is eased as all are able to access the photographs. For subsequent visits, pictures are able to be accessed and used as a comparison from the computer screen to current the state of wound or ostomy. This allows all providers to assess the effectiveness of current treatments. Photos are taken prior to physician assessment and following a wound debridement. This allows providers to visualize the healthy wound bed and peri wound. Accurate and efficient uploading photo documentation ensures continuity of care in our facility spectrum.