Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient’s medical record. Pictures in wound care can be used to ensure accuracy of measurements, to encourage objective assessments, to reduce the risk of misinterpreting the cause of the wound, as a teaching resource to both patients and new clinicians, and to encourage the use of evidence-based practices. In providing wound care from a distance such as through telewound services, wound photos are taken to help in diagnosis and treatment.

The quality of the photo may vary depending on the person taking the photo (clinician, caregiver, patient). However, the emphasis is on using the photo in conjunction with the patient’s clinical wound descriptions and medical history, thereby evaluating the wound, treatment plan, and healing progress.^1-3

Clinical documentation is a legal, moral, economic, and professional responsibility.⁴ Wound photos supplement the written record but should never replace it.⁵ Despite the value of wound photography, not all health care settings provide wound photo documentation software or include this as a part of their wound care policies and procedures. The facility or agency should always discuss this issue with the risk manager or legal counsel because each state has its own rules on the use of images.⁶

Photos in Wound Care

Wound photos are valuable for various reasons, including assisting dressing selection, validating healing status, correcting wound classification, and planning care. Wound photographic documentation provides a faster method for injury discovery on admission and date of onset and for reporting progression or regression of wound status.⁷ Patients are normally asked on admission for consent to photography (photo identification, wound, etc.). In the past, clinicians took pictures of the wound with Polaroid cameras and would then tape the photo to the patient’s chart.

Polaroid images did not always have proper lighting, and there was always the risk that the image would become detached from the chart and lost. Additionally, dates and notes on the image would need to be written down in the chart, or possibly on the image itself. Camera technology has evolved into a more streamlined method that helps to facilitate mapping of wound status timelines from admission to discharge. Photos may now be taken with a digital camera and uploaded to the patient’s electronic medical record (EMR) or with a smartphone that connects directly to the EMR.⁷ These methods often automatically record the date the image was taken, and most modern cameras have automatic methods of correcting light exposure to ensure a more accurate picture of the wound.

Tips for Taking Photos of Wounds

Clinicians should be trained effectively in providing consistent photographs.¹ The policy and procedure for taking wound images during wound assessment should include a systematic process in how to take the best-quality and correct image (lighting, distance), how to label the image, and how to attach the image to the EMR. Duplicated photos, poor-quality photos, and photos not labeled with patient identification should be deleted.⁷ Wound care photos can be used to help strengthen various areas of a practice for providers and clinicians. Communication between providers and nurses during wound deterioration or changes in wound status can be utilized, but we always need to consider HIPAA compliance. Taking photos has now become part of everyday practice in many facilities (depending on policies) for inclusion in the patient’s EMR. Wound photos help with numerous assessment components, including:

• Wound size
• Wound depth
• Wound tissue and amount (granulation, slough, eschar, epithelial)
• Quality of wound edges and the periwound area (maceration, epibole, shape)
• Pre- and post-debridement wound status, to validate effectiveness

Using Photos to Create a Timeline of Wound Healing

Photos are a good way to create a timeline and can help identify issues. For example, if a patient under your care with a stage 2 pressure injury is transferred to the hospital and then returns with a stage 3 pressure injury, the wound photos may validate where the pressure injury worsened and may thus allow for further investigation into the quality of care received at the time of wound deterioration. Also, if a nurse documents the stage 2 pressure injury before the patient was transferred and the photo clearly identifies granulation in the wound, the wound should have been documented as a stage 3 pressure injury.

Having the photographic evidence of the wound’s status would allow for a correction to be made to the documentation and prevent potential accusations of improper care. If your patient had a previous admission with the same wound, these photos can be helpful in identifying the correct cause of the wound, the date of onset, and progression and regression in healing status. To ensure usable data, the following criteria should be met:

• All photos should be attached to a progress note or report.
• Take photos before and after debridement.
• Number wounds for better tracking.
• Take photos of the wound from the same position or angle.

Consider taking images during the following timeframes⁷:

• Admission, the initial head-to-toe skin assessment: Images should be taken within 24 hours to validate when the wound was identified. Consent for photos should be part of the admission process.
• New wound: Photos should be taken within 24 hours of wound discovery. Always follow your facility protocol in reporting a new wound.
• Weekly wound assessment: Weekly wound assessments should preferably occur on the same day each week, with images of the wound taken at each assessment. Compare wound images to evaluate healing progress.
• Discharge: Take wound images before discharge to provide a record of skin and wound status.

Why Photo Documentation is Important in Wound Care

Images should be reviewed for inaccuracies such as inconsistent color, out-of-focus images, and inconsistent orientation. Wound photos will not always be perfect, but they can be used to justify the course of care from a quality of care and reimbursement standpoint, so it is critical to try to take clear and consistent images. The Centers for Medicare & Medicaid Services are known to audit regularly, and wound photos provide supporting evidence. More than 17,000 lawsuits are related to pressure injuries annually in the United States.

It is the second most common claim after wrongful death.⁸ Proper documentation proving quality of care will help prevent potential legal issues. Wound photography can be used in helping defend medical malpractice cases. Especially in patients with pressure injuries, malpractice lawsuits are most common, and wound photos can assist in validating quality of care, can help protect facilities from legal implications, and ultimately are used as a tool to record the wound location, date, and time validating wound status.⁹ Always explain to patients the importance of photos as part of their medical record. Explain that photos are used to track their wound progress and support better care. Involve your patients in their wound care when possible and offer to review their wound report and images with them. Use these times as an educational opportunity and to keep patients hopeful by showing them how their wound has progressed toward healing.

Discuss healthy tissue versus dead tissue, measurements, and treatment, and strive for positive feedback in adherence to the care plan. Using images may also help the patient and family understand the serious nature of the wound and assist in making choices.³ When reviewing wound images in a timeline, the provider or clinician can determine whether there is wound healing progress, no advancement toward closure, declination, changes in tissue types and percentages, and changes in periwound health. Some wound assessment and monitoring systems that can be downloaded to the EMR have the capability to compare wound progression data, flag stagnation of wounds, and track healing progress over time. These systems can be used to help evaluate data and streamline the documentation creation process.

Conclusion

Wound photos are paramount in enriching documentation and encouraging better overall patient care. Creating a consistent timeline of wound images enhances identification of issues while providing a way to involve patients in their care. Showing patients their wound progress can lead to better adherence to the care plan and can provide encouragement to patients.

References

1. Bradshaw L, Gregar M, Hooko G. Collaboration in wound photography competency development: a unique approach. Adv Skin Wound Care. 2011;24: 85-92.

2. Hamilton A, Fielder K. Digital Photography in Wound Management. WoundsWest IT Solution – MMeX pilot 2010. University of Western Australia.

3. Wang SC, Anderson JA, Jones DV, Evans R. Patient perception of wound photography. Int Wound J. 2016;13(3):326-330.

4. Applegate MI. Ethics. In: Black JM, Matassarin-Jacobs E, eds. Luckmann and Sorensen's Medical-Surgical Nursing: A Psychophysiologic Approach. 4th ed. Philadelphia, PA: WB Saunders; 2000.

5. Pasqualone GA. The role of photography in the emergency room: an ER nurse's perspective. Polaroid. http://www.polaroid.com/instantevidence/instantevidence_12_02_hc.html. Accessed January 6, 2020.

6. Langemo D, Hanson D, Anderson J, Thompson P, Hunter S. Digital wound photography: points to practice. Adv Skin Wound Care.2006;19(7):386-387. 7. Estocado N, Black J. Clinical Practice. Ten top tips: wound photo documentation. Wounds Int. 2019;10(3).

8. Berlowitz D, Parker V, Niederhauser A, et al. Are we ready for this change? In: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality; 2012; last reviewed 2014. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure…. Accessed January 22, 2021. 

9. Calianno CA, Martin-Boyan A. When is it appropriate to photograph a patient’s wound? Adv Skin Wound Care. 2006;19(7):304-306.