Policy for Recordings and Photography - the Royal Cornwall ...

Document TitleType of documentPolicy for Recordings and PhotographyCorporate: Non ClinicalBrief summary of contentsExecutive Director responsible forPolicy:Directorate / Department responsible(author/owner):Policy for Recordings and PhotographyThis Policy ensures that all recordings,whether originating in the MedicalPhotography Department, or using camerasowned by departments within the Trust, whichillustrate a patient’s condition or an aspect ofthe treatment, form a part of that patient’shealth record and are protected in the sameway as any other health record. In this Policy,the term “recording” (or “recordings”) is usedto refer to photography (either conventional ordigital), video recording (either conventional ordigital), clinical imaging and voice recordingsin Speech and Language Therapy.It refers to originals and/or copiesDirector of FinanceContact details: 01872 254500Date written: 8 September 2005Date revised: 19 April 2012Approval route (names ofcommittees)/consultation:Divisional Manager confirming approvalprocessesName and Post Title of additionalsignatoriesEquality Impact Assessment appendedApproval must not be given if the EIS isnot attachedSignature of Executive Director givingapprovalPublication Location (refer to Policy onPolicies Appendix 1):Document Library Folder/Sub FolderKim Bellis, Records Services, PAS & DataQuality Manager, Health Informatics and ICTInformation Governance CommitteeHealth Records User GroupConsultants in Child Health, Breast Surgery,Clinical ImagingMedical PhotographyDermatology DepartmentNot applicableNot applicableYesPage 1 of 25{Original Copy Signed}Internet & Intranet X Intranet OnlyHealth Informatics

Date of final approval: 27 July 2011Date policy becomes live: 1 August 2011Date due for revision: 1 August 2014Links to key external standardsRelated Documents:Suggested Keywords:Training Need Identified?NHS Litigation AuthorityCare Quality Commission – Outcome 21Information Governance ToolkitPatient Record and Information ManagementAccreditation ProgrammeData Protection Act 1998Access to Health Records Act 1990NHS Code of ConfidentialityNHS Records Management Code of PracticeGMC Guidance Making and using visual andaudio recordings of patientsRCHT:Information Governance PolicyManaging Health Records PolicyClinical Record Keeping PolicyData Protection PolicyPhotographers, Photography, Photographicequipment, Photographs, Imaging, Imaging[digital], Imaging [medical], Video cameras,Video recording, Video recordings, Videotapes, Videos, Audio recordings, Audio tapes,Medical photographers, Medical photographicequipment, Medical photography, Medicalphotography departments, RecordingsNoThis document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Policy for Recordings and PhotographyPage 2 of 25

Policy for Recordings and PhotographyV2.419 April 12Policy for Recordings and PhotographyPage 3 of 25

Version Control TableDateVersionNoSummary of Changes8 Sep 05 V1.0 Original document created10 Nov 10 V2.0 First major revision4 April 11 V2.1Formatted to Policy on Policies standardtemplateInclude Internal Audit recommendations6 June 11 V2.2 Include update from GMC guidance issued27 June 11 V2.3 Include comments from consultation andchange name of Policy19 April 12 V2.4 Updated to reflect changes as a result of aSerious Incident – availability of digitalcameras out of normal office hoursChanges Made by(Name and Job Title)Kim BellisRecords Services MgrKim BellisRecords Services MgrAndrew RogersCorporate RecordsManagerKim BellisRecords Services & PASManagerKim BellisRecords Services & PASManagerKim BellisRecords Services & PASManagerKim BellisRecords Services, PASand Data Quality ManagerAll or part of this document can be released under the Freedom of Information Act2000This document is to be retained for 10 years from the date of expiry.Policy for Recordings and PhotographyPage 1 of 25

NHS UnclassifiedTable of ContentsVersion Control Table...................................................................................................11. Introduction...............................................................................................................32. Purpose of this Policy ...............................................................................................33. Scope .......................................................................................................................34. Definitions / Glossary................................................................................................35. Ownership and Responsibilities................................................................................36. Standards and Practice ............................................................................................46.5. Confidentiality....................................................................................................46.9. Consent .............................................................................................................56.43. Processing ...................................................................................................106.52. Storage and disposal. ..................................................................................116.59. Disclosure of Recordings .............................................................................116.61. Copyright......................................................................................................127. Dissemination and Implementation.........................................................................128. Monitoring compliance and effectiveness...............................................................129. Updating and Review..............................................................................................1410. Equality and Diversity..........................................................................................1410.2. Equality Impact Assessment........................................................................14Appendix 1. General Consent to Recording...................................................................15Appendix 2. Genito Urinary Medicine Consent to Recording.........................................17Appendix 3. Request for Medical Photograph................................................................19Appendix 4. Initial Equality Impact Assessment Screening Form ..................................20Policy for Recordings and PhotographyPage 2 of 25

NHS Unclassified1. Introduction1.1. It is essential that the Trust respects the confidentiality of patients and staffand, in so doing, abides with the requirements of the Data Protection Act, otherextant legislation and Trust policies. This legislation demands that images andrecordings are treated in the same way as other personal data however, theserecordings require different handling arrangements due to the amount ofinformation that they contain and the ability of such recordings to be manipulated.1.2. This version supersedes any previous versions of this document.2. Purpose of this Policy2.1. This policy is intended to standardise the way that Trust staff handle imagesand recordings to ensure that confidentiality is maintained and that the Trust canmeet its obligations with respect extant legislation.3. Scope3.1. This policy applies to all Trust staff members undertaking the capture,processing, storage and retrieval of images and recordings in the course of theirduties. This includes recordings made:• On healthcare premises within or outside the UK (including Theatres) and/or• As part of the assessment, investigation or treatment of patients’ conditions orillness and may include video links in Theatres, and/or• For purposes such as teaching, training or assessment of healthcareprofessionals and students, research, or other health-related uses which are notdesigned to benefit the patient directly, described as ‘secondary purposes’4. Definitions / Glossary4.1. Recording. Recording refers to clinical imaging, photography, video andvoice recordings in Speech and Language Therapy but excludes recordings oftelephone conversations, pathology slides containing human tissue or CCTVrecordings of public areas in hospitals. This includes mobile phones. Within thecontext of this policy recordings may be:Conventional (analogue) or digital;Originals or copiesRecordings in this guidance does not include pathology slides containing humantissue. Photographs of slides may be made without consent for the purpose ofcare or treatment of patient, or for secondary purpose, provided that images areanonymised or coded.5. Ownership and Responsibilities5.1. Role of the Managers5.2. Line managers are responsible for:Policy for Recordings and PhotographyPage 3 of 25

NHS UnclassifiedEnsuring that any of their staff members involved with the capture, processing,storage and retrieval of audio, video and photographic recordings are aware of,and comply with, this policy.To notify the Records Services & PAS Manager if recordings are undertaken inyour department (not for each and every individual recording)5.3. Role of Individual Staff5.4. All staff members are responsible for:Ensuring that their Line Manager is aware of any audio, video andphotographic recording activity in their work area.To notify the Records Services & PAS Manager if recordings are undertaken inyour departmentEnsuring that they abide by this policy if they are involved with any audio, videoand photographic recording activity.Reporting any breaches of this policy to the Records Services and PASManager.Medical Staff are reminded that serious or persistent failure to follow this policywhich is based upon GMC Guidance may put their registration at risk6. Standards and Practice6.1. Recordings, whether originating in the Medical Photography Department orusing cameras purchased for departments use (and sometimes purchased fromcharitable funds), which illustrate a patient’s condition or an aspect of thetreatment, form a part of that patient’s health record and are protected in the sameway as any other health record.6.2. Under no circumstances should staff use their mobile phones or personalcameras to record images.6.3. Freelance professional photographers are sometimes employed to make thissort of recording. They may only be introduced to The Royal Cornwall HospitalNHS Trust by arrangement with the Press Officer or Director of Communications.6.4. All equipment used for recordings must be purchased through the CornwallIT Services Helpdesk. Your request will be logged and the Records Services &PAS Manager will contact you to seek assurance of your compliance with thispolicy specifically around the use, storage, security and access of images. Oncethis has been established approval will be given to purchase the equipment.6.5. In the event of a digital photograph needing to be taken urgently out ofnormal office hours there is a digital camera available on the Neonatal Unit and theEmergency Department that may be used. They must be returned immediatelythey have been finished with.6.6. Confidentiality6.7. Confidentiality is the patient’s right and may usually only be waived by thepatient or by someone legally entitled to do so on his/her behalf. You arereminded that breach of confidentiality may well amount to serious professionalPolicy for Recordings and PhotographyPage 4 of 25

NHS Unclassifiedmisconduct with inevitable disciplinary consequences and could result insubstantial financial damages.6.8. In order to ensure that the patient’s right to confidentiality is preserved, TheRoyal Cornwall Hospital NHS Trust requires that: The patient’s consent is obtained in writing for the original recording and for itsuse as a part of treatment or for teaching in Cornwall (with the exception of thoselisted in the section Recordings for which separate consent is not needed, whichare exempt), or for further specified use, such as publication; The Medical Photography department will only produce copies of medicalphotographs upon receipt of the original consent form. Copies must only bemade for official RCHT purposes, or as part of a disclosure under the DataProtection Act 1998 or Access to Health Records Act 1990; Prior to publication in journals, books or elsewhere, the patient’s permissionfor the specific use proposed is sought and written consent obtained.6.9. All projects/research involving recording patients must be registered with theResearch Department as part of the overall research project.6.10. Consent6.11. Proper informed consent for recording and disclosure must be obtained if therecording is made as part of the assessment or treatment of patients. SeeAppendix 1for the general consent form and Appendix 2 for the Genito UrinaryMedicine (GUM) consent. This must be recorded in the patient’s health record forthe general consent and within the Sexual Health Hub for the GUM consent. Acopy should be given to the patient and also the Medical Photography Departmentif appropriate.6.12. Information Link, Medical Illustration, the Electronic Document Library andhigh use areas of medical photographs should display a “Notice to Patients”explaining the extent of the consent they are being asked to sign. Consent formsare available as part of this Policy Document on the Electronic Documents Libraryor downloaded from the Records Management website.6.13. The practice of obtaining the patient’s written consent only in the case of fulllength or facial recordings, from which the patient can easily be identified, is notsufficient. It is sometimes possible for people to be identified from other categoriesof recording, e.g. showing a tattoo or other distinguishing mark. Nor is it sufficientto rely on the photographer or consultant’s judgement that a particular patient isunlikely to be identified from a particular recording.6.14. The Royal Cornwall Hospital NHS Trust has therefore adopted the policy thatinformed consent to recording is obtained from all patients and in all cases (exceptthose that are exempt). Remember those recordings taken as part of treatment orassessment are part of the patient’s health record and must be treated in the sameway as written notes.Policy for Recordings and PhotographyPage 5 of 25

NHS Unclassified6.15. In the case of procedures, recording is implicit (e.g. endoscopy), consent tothe procedure provides implicit consent to recording under normal conditions.Health professionals must ensure that they make clear in advance thatphotographic or video recording will result from the procedure.6.16. In all cases of recording, care must be taken to respect the dignity, ethnicityand religious beliefs of the patient.6.17. Patients have the right to withdraw consent for use of their recordings at anytime. Patients should not be placed under pressure to give their consent for therecording to be made. If a patient decides to withdraw consent, the records mustnot be used and, if made in the context of teaching or publication, destroyed.6.18. In the case of electronic publication, it should be made clear to the patientthat once a recording is in the public domain; there is no opportunity for effectivewithdrawal of consent already given.6.19. Children or young people. If children are competent to give consentfor themselves, you should seek consent directly from them. The legalposition regarding competent is different for children aged 16 and 17 and forthose under 16. Children or young people under the age of 16 who are assessedas having the capacity and understanding to give consent for a recording may doso. However, they should be encouraged to involve their parents or those withparental responsibility in the decision making. Where a child or young person isnot able to understand the nature, purpose and possible consequences of therecording you must obtain consent from a person with parental responsibility.6.20. Recordings of children or young people should only be taken if there arespecific features that need recording for clinical reasons (e.g. assessing theprogression of a skin lesion) or teaching (e.g. an important clinical sign that mightonly be seen rarely). Recordings should only include the specific areas of interest,whole body images should only be taken if completely necessary. Recordings ofgenital areas must only be taken if deemed absolutely necessary and appropriate.Recordings of the chest in peri or post pubescent girls must only be taken ifdeemed absolutely necessary. It is strongly recommended that a clear indicationbe recorded in the patient’s health record justifying the recording in both of theseevents.6.21. In cases where a video or audio recording are to be made and the child isdeemed to be of an age and understanding to give consent then their consentshould be recorded on the video/audio at the beginning of the recording.6.22. Unconscious Patients. Photographs of unconscious patients may only betaken with consent from the next of kin. Once the patient has regainedconsciousness they must be informed that a photograph has been taken and ifthey object to the use of the photograph, it must be destroyed. This must all bedocumented in the patient’s health record.6.23. Psychiatric Patients. The recording – especially on video – of psychiatricpatients requires particular care, guidelines for these procedures have beenpublished by the Institute of Medical Illustrators (Code of Responsible Practice,Policy for Recordings and PhotographyPage 6 of 25

NHS Unclassifiedpublished 1996 and updated 1998, available from The Hon. Secretary, Institute ofMedical Illustrators, Medical and Dental Illustration Unit, Leeds Dental Institute,Clarendon Way, Leeds, LS2 9LU)6.24. Patients who lack capacity. If you judge that an adult patient lackscapacity to consent to an investigation or procedure which involves a recording,you must obtain consent from someone who has legal authority to make thedecision on the patient’s behalf before making the recording. If there is not legalauthority to make the decision on a patient’s behalf, or where treatment must beprovided immediately, recordings may still be made where they form an integralpart of an investigation or treatment that you are providing in accordance with therelevant legislation or common law. Note: Enduring Power of Attorney does notextend to authority over health matters, if you need further guidance on this pleasecontact the Data Protection Officer.6.25. In the case of recordings for secondary purposes, you must not assume thatbecause a patient lacks capacity to make some decisions that they lack capacity tomake any decisions at all, or will not be able to make the decision in the future.Before deciding if patients have capacity to make a decision, you must take allpractical and appropriate steps to enable them to make the decision forthemselves, and considering the use of simple language or visual aids or byinvolving a carer or family member.6.26. For further advice about involving adults who lack capacity, in researchwhere recordings may form part of the research, see GMC Guidance on Consentto Research.6.27. Deceased Patients. If a patient dies before a retrospective consent can beobtained, material by which the patient is identifiable can only be released with theconsent of the deceased’s personal representatives. In addition wherever possiblethe consent of the next of kin or near relatives should be obtained, particularlywhere the personal representatives are not relatives of the deceased. You shouldfollow a patient’s known wishes after their death. You are reminded that the dutyof confidentiality survives the death of the patient and you and the Trust can beprosecuted under the Access to Health Records Act 1990.6.28. If a consenting patient subsequently dies, permission should be sought forany new use outside the terms of the existing consent. In this instance theconsent of either the personal representative or the next of kin is required, unlessthey are one of the same.6.29. If the recording will be in the public domain or the patient is identifiable youwill need to consider whether the patient’s family should be consulted. For furtherguidance you should seek legal advice through the Records Services & PASManager or from your medical defence organisation.6.30. Post Mortem Examinations: Post mortem examinations are governed bylegislation in the UK. Recordings may form an integral part of a post mortemexamination and separate consent is not needed for making recordings of bodyorgans, body parts or pathology slides to assist in the cause of death. Howeverrelatives should expect that information is given to them to explain why a recordingPolicy for Recordings and PhotographyPage 7 of 25

NHS Unclassifiedmay be made. If you wish to make recordings for secondary purposes such astraining, teaching or research you should seek consent at the same time you seekconsent to undertake the examination. If you have not foreseen this possibility,you may make recordings for secondary purposes without consent provided thatthey do not include images that might identify the person. In the case of aCoroner’s post mortem consent must be sought from the Coroner to use theinformation. Recordings can only be taken on specific equipment and bynominated individuals. A list of those permitted to undertake recordings will beheld within the department in the department. A record is kept of all recordingstaken and is audited within the department.6.31. Non-Clinical Recording. In cases where the patient is incidental to arecording, e.g. where the picture is to illustrate a particular equipment set-up,consent to appear in the recording is still required from any patient or member ofthe public. This should be specific and detailed as described in the ‘Confidentiality’section above.6.32. Accidental recording of patients who have not given appropriate consentmust be avoided. Images of a patient that have inadvertently picked up theimages of another patient or patients who have not consented should not bepublished under any circumstances. Unless deleterious to the care of the subjectpatient, they should be destroyed.6.33. Members of staff who normally operate the equipment in a recording aredeemed to have given their consent to the recording and its further use byappearing in the recording. If the member of staff does not normally work in thatarea, then consent should be obtained and filed.6.34. There may be occasions where meetings are recorded, for example in thecase of Local Resolution Meetings in response to a formal complaint or a generalmeeting within the hospital where this is used to type the minutes of the meeting.In these cases consent within the group attending the meeting should be sought.Once the notes/minutes have been typed and ratified the recording should bedisposed of in line with Trust Policy if recorded by the Trust. Patients attendingLocal Resolution meetings may well bring their own recording equipment,providing all attending consent to this taking place then this should be allowed.6.35. Recordings may be made to aid consultation and the patient may be given acopy of the recording. These requests must be managed through the DisclosureOffice.6.36. Recordings for which separate consent is not needed. You do notneed to seek permission to make the recordings listed below, nor do you needconsent to use them for any purpose, provided that, before use, the recordings areeffectively anonymised by the removal of any identifying marks: Images taken from pathology slides X-rays Laparoscopic and endoscopic images Images of internal organs Recordings of organ functionsPolicy for Recordings and PhotographyPage 8 of 25

Ultrasound images CT MRI Nuclear Medicine Images Radionuclide ImagingNHS Unclassified6.37. Such recordings will not identify the patient. It may nonetheless beappropriate to explain to the patient, as part of the process of obtaining consent tothe treatment or assessment procedure that a recording will be made. You maydisclose or use any of the above recordings for secondary purposes withoutseeking consent provided that, before use, the recordings are anonymised.6.38. In exceptional circumstances, recording may be necessary without consent,for example in the case of a child with injuries where abuse is suspected. Aperson with parental responsibility should be informed of the reasons for clinicalphotography, and should be given the opportunity to consent. The parents’responses should be recorded. The agreement of the child, if of sufficientunderstanding should also be sought. In the absence of parental consent,photography should be authorised only by a senior doctor with child protectionresponsibility for the case. Recordings taken in these cases may be required asevidence in criminal or public proceedings and no absolute guarantees ofconfidentiality in this respect can be given.6.39. Recordings made for research, teaching, training and otherhealthcare-related purposes. To address the issue of existing collections thatare used for teaching and training, you may continue to use anonymisedrecordings as well as those that identify the patient as long as you have a recordthat consent was obtained for the recording to be made or used. You must notuse recordings for which there is no record of whether consent was obtainedwhere it is clear from the context that consent had not been given to the recordingor the patient is, or may be, identifiable.6.40. For current recordings you must obtain consent for teaching, training, theassessment of healthcare professionals and students, research or other relatedhealthcare-related purposes. It is always good practice to get written consent butverbal consent is considered sufficient if written consent is not practicable. Eitherconsent should be stored with the recording.6.41. Recordings for use in widely accessible public media (television,radio, internet, print). You must obtain the patient’s consent, which shouldusually be in writing to make a recording that will be used in widely accessiblemedia, whether or not you think the patient will be identifiable from the recording.If the recording was anonymised it is still considered to be good practice to seekconsent before publishing it. Before any arrangement is made to undertake suchrecordings you must obtain agreement from your employer, you must contact thePress Officer to see if such a contract exists. Patients must understand that oncethey have agreed to the recording being made for broadcast, they may not be ableto stop it subsequent use. If the patient wishes to restrict the use of the recordingthey should be advised to get agreement in writing from the programme maker andthe owners of the recording, before recording begins.Policy for Recordings and PhotographyPage 9 of 25

NHS Unclassified6.42. You must not participate in making or disclosing recordings of children oryoung people who lack capacity, where you believe that they may be harmed ordistressed by making the recording, even if the person with parental responsibilityhas given consent.6.43. Recordings of adults who lack capacity that have been made in accordancewith legal requirements may be disclosed for use in the public media, where thiscan be justified in the public interest. Where a person has legal authority to act onbehalf of the patient, they will need to assess and decide whether disclosure isjustified in the public interest.6.44. Making recordings covertly. Covert recordings should be undertakenonly when there is no other way of obtaining information which is necessary toinvestigate or prosecute a serious crime, or to protect someone from serious harm,as in the case of suspected child abuse. Before any covert recording can bemade, authorisation must be sought from Trust senior management guided by theTrust’s named professionals for safeguarding. In most cases covert recordings willbe carried out by the Police and falls in the scope of the Regulation ofInvestigatory Powers Act 2000.6.45. Recording telephone calls. Telephone calls from patients to healthcareorganisations may be recorded for legitimate reasons such as medico legal,training and audit as long as you have taken all reasonable steps to inform thecaller that their call may be recorded. You must not make secret recordings ofpatients.6.46. Processing6.47. It is recognised that while digitally originated recordings are intrinsically nodifferent to traditional recordings; they are easier to copy in electronic form and aretherefore more at risk of both image manipulation and inappropriate distribution.Particular care must be taken to protect the image and maintain its integrity.6.48. A patient’s image may not be altered in any way to achieve anonymity and soavoid the need for consent. Blacking out of the eyes in a facial photograph is notacceptable means of anonymising the image.6.49. Where digital photography is to be used to record images of patients, duecare must be given before the start to ensure that the quality of the image (in termsof both resolution and colour depth) is adequate for purpose.6.50. In order to maintain the integrity of the image, manipulation may only becarried out to the whole image, and must be limited to simple sharpening,adjustment of contrast and brightness and correction of colour balance.6.51. Images of patients may only transferred to personal computers for use inconnection with Ethical Committee approved and Data registered researchprojects or for the preparation of teaching materials for use in accordance with the‘Confidentiality’ section above. All images must be anonymised.6.52. It is recognised that images issued by the Clinical Imaging Department maynot be in the best format for reproduction, it is the requirement of many journalsPolicy for Recordings and PhotographyPage 10 of 25

NHS Unclassifiedthat there is radiological input with the Radiologists preparing the images forpublication prior to the capture in photographic or digital form. In all cases ofreproduction the Royal Cornwall Hospital NHS Trust retains both the right toapprove the quality, relevance and accuracy of the images and their copyright.6.53. Requests for recordings from the Medical Photography Department must bemade on the approved request form at Appendix 36.54. Requests for recordings of private patients must first be processed throughthe Outpatient Services Manager before being sent to the Medical PhotographyDepartment.6.55. Storage and disposal.6.56. All recordings of patients must be stored on Trust premises. Negatives,master transparencies, original digital camera files and videotapes must be loggedand stored on Trust supplied secure servers (never on your local machine). In thecase of digital cameras, the files must not be treated in any way (includingcompression) before storage.6.57. Recordings that may be considered ‘highly sensitive’ (child abuse forexample, or neonatal deaths) must be given due consideration as to how andwhere these are stored. Access to these recordings must be restricted to thosestaff that have specific authority to access them.6.58. Since any health record has to be available for disclosure if required, it isessential that every recording is properly logged in the patient health record, alongwith the file location. Each recording must be labelled so as to uniquely identifythe patient.6.59. In the case of hard copy photographic negatives and transparencies, thesemust be securely stored and logically catalogued within the department that therecording was taken.6.60. Historically images were stored on CD/DVDs, if you cannot locate an imagewithin the patient health record this may be accessed through the DisclosureOffice.6.61. Since recordings are considered to be part of the patient health record allappropriate criteria pertaining to health records must be taken into considerationbefore any form of disposal takes place. The Managing Health Records Policycontains guidance on the retention and disposal of all health records, the Policycan be found on the Document Library on the Trust’s Intranet.6.62. Disclosure of Recordings6.63. Recordings made as part of the patient’s care form part of the Health Record,and should be treated in the same way as written material in terms of security anddecisions to disclose information. All requests to disclose recording must bechannelled through the Disclosure Office.Policy for Recordings and PhotographyPage 11 of 25

NHS Unclassified6.64. Copyright6.65. Copyright of all recordings taken by Trust staff in the course of their duties isvested in the Royal Cornwall Hospital NHS Trust.6.66. Recording for media purposes or in instances where the Trust allows itsbuildings to be used as filming locations the copyright is retained by the productioncompany.6.67. Contracts with outside photographers must ensure that that they waiveownership of copyright and moral rights in the recordings they prepare, althoughthey may still be allowed to reproduce the recording or medical image providingpermission has been given from the Royal Cornwall Hospital NHS Trust on eachindividual occasion. It is important that in any contract for publication the copyrightin the recording remains with the Trust and does not pass automatically to thepublishers on first publication, otherwise the Trust might well find itself unable toprotect the patient’s interests by exercising control over further publication of therecording.6.68. Those signing contracts with book or other publishers have a responsibility todelete from the contract any suggestion that the copyright will pass to thepublishers.6.69. Junior doctors and others acquiring copies of recordings in the course of theirduties may retain these for teaching purposes, but must undertake only to usethem within the terms of the original consent (see the section on ‘Confidentiality’above). Copyright and reproduction rights at all times remain with The RoyalCornwall Hospital NHS Trust.6.70. Copies of recordings must not be excessive and may be made only afterdiscussion with the Medical Photography Department; decisions will be made caseby case and on its own merit.6.71. Before leaving the employment of the Trust, staff must seek specificpermission to retain images for teaching purposes from the Data ProtectionOfficer. The Royal Cornwall Hospital NHS Trust may grant such permissionsubject to the retention of copyright and all reproduction rights.7. Dissemination and Implementation7.1. This policy will be disseminated to all Trust staff members via the DocumentLibrary and via routine communications, such as team briefings and ‘all-users’emails, with Senior Management, Line Managers, Records Management Leads,Information Asset Owners and staff members. The previous version of this policywill be archived within the Document Library.7.2. The Trust will ensure that this policy has been implemented through spotchecks carried out by the Trust’s Records Services Department and audit.8. Monitoring compliance and effectiveness8.1. The requirements of this policy will be subject to audit and spot checks.‘Reporting by Exception’ will be employed in routine reports on the effectiveness ofPolicy for Recordings and PhotographyPage 12 of 25

NHS Unclassifiedthe arrangements contained within this policy provided to the InformationGovernance Committee and the Health Records User Group.Element to bemonitoredHas the recording been stored on a Trust server and appropriateaccess controls been applied? It is unacceptable to store imageson mobile phones.Has the recording taken been documented in the patient paperhealth record along with the locationLeadToolHas consent been obtained and filed in the patient paper healthrecordRecords Services & PAS ManagerMethodologyMaintain a record of which departments have notified the RecordsServices & PAS Manager of recordings being made and theirlocationsCross reference with patient paper health record to see if this imagewas recorded in the record and the location of the stored image forfuture disclosures.FrequencyReportingarrangementsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedComplete an audit form detailing location, access and reference topatient recordQuarterly. Over a 12 month period a sample of recordings will beaudited for all DivisionsThe Health Records User GroupThe Records Services and & PAS Manager will include this in thequarterly monitoring report tabled at the Health Records UserGroup.Information Governance CommitteeThe minutes and report tabled at the Health Records User Groupare presented to the Information Governance Committee forinformation by the Records Services & PAS ManagerThe Records Services & PAS Manager will in conjunction withthe Health Records User Group, undertake subsequentrecommendations and action planning for any or all deficienciesand recommendations within reasonable timeframes.The subsequent action plan will identify the recommendation anda specified timeframe for implementation.Any system or process changes or lessons learnt will be sharedwith the Health Records User Group and the InformationGovernance Committee. This will also be shared with theIdentified Records Management Leads, Data Quality andInformation Asset Leads as well as through the Daily Bulletinand For the Record publication. Following any change theRecords Services & PAS Manager will arrange to re-audit.Policy for Recordings and PhotographyPage 13 of 25

NHS Unclassified9. Updating and Review9.1. This policy will normally be reviewed no less than every three years unlessan earlier review is required.10. Equality and Diversity10.1. This document complies with the Royal Cornwall Hospitals NHS Trustservice Equality and Diversity statement.10.2. Equality Impact Assessment10.3. See Appendix 4.Policy for Recordings and PhotographyPage 14 of 25

NHS UnclassifiedAppendix 1. General Consent to RecordingPolicy for Recordings and PhotographyPage 15 of 25

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NHS UnclassifiedAppendix 2. Genito Urinary Medicine Consent to RecordingPolicy for Recordings and PhotographyPage 17 of 25

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NHS UnclassifiedAppendix 3. Request for Medical PhotographPolicy for Recordings and PhotographyPage 19 of 25

NHS UnclassifiedAppendix 4. Initial Equality Impact Assessment ScreeningFormName of policy, procedure or service (hereafter referred to as policy) to beassessed: Medical Photography and Video Recording of Patients PolicyDirectorate and service area:Is this a new or existing Policy?Health InformaticsExistingName of individual completingTelephone: 01872 25 4500assessment: Kim Bellis1. Policy Aim* This policy is intended to standardise the way that Truststaff handle audio, video and image recordings throughthe implementation of robust procedures.2. Policy Objectives* To ensure that confidentiality is maintained and that theTrust can meet its obligations with respect extantlegislation.3. Policy – intendedOutcomes*4. How will you measurethe outcome?5. Who is intended tobenefit from the policy?6a. Is consultationrequired with theworkforce, equality groupsetc. around this policy?A consistent approach across the Trust to the handlingof audio, video and image recordings leading toimproved integrity of health records.Spot checks and audit.All staff and patients.Nob. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this policy.N/AInformation Governance Committee7. The ImpactPlease complete the following table using ticks. You should refer to the EIA guidancenotes for areas of possible impact and also the Glossary if needed.• Where you think that the policy could have a positive impact on any of theequality group(s) like promoting equality and equal opportunities or improvingrelations within equality groups, tick the ‘Positive impact’ box.• Where you think that the policy could have a negative impact on any of theequality group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.• Where you think that the policy has no impact on any of the equality group(s)listed below i.e. it has no effect currently on equality groups, tick the ‘No impact’box.Policy for Recordings and PhotographyPage 20 of 25

NHS UnclassifiedIt is important that there is clear evidence for the decision on whether the policy,procedure or service has a positive, negative or no impact. This may be through:• Knowledge of e.g. the culture of a particular ethnic group• Complaints• Surveys• Performance data• Inspection/audit/ assessment• Anecdotal evidenceEqualityGroupPositiveImpactNegativeImpactNoImpactReasons for decision(including evidence)AgeYoung, old & middle aged peopleDisabilityPeople who have a disability thatmay be physical, mental orsensory, visible or non-visible.This policy addressesthe management ofphotography andrecording equally,irrespective of equalitygroupThis policy addressesthe management ofphotography andrecording equally,irrespective of equalitygroupReligion & BeliefPeople who have a religiousbelief, people who are atheist oragnostic, people who have aphilosophical belief which affectstheir view of the worldGenderMen, women, married people,transsexual, transgender,parenting, caring, flexible working& equal pay concernsRacePeople from the various racialgroups, e.g. as contained withinthe censusSexualOrientationHeterosexual & bisexual men andwomen, gay men & lesbiansHuman RightsAll areas (Articles) of the HumanThis policy addressesthe management ofphotography andrecording equally,irrespective of equalitygroupThis policy addressesthe management ofphotography andrecording equally,irrespective of equalitygroupThis policy addressesthe management ofphotography andrecording equally,irrespective of equalitygroupThis policy addressesthe management ofphotography andrecording equally,irrespective of equalitygroupThis policy addressesPolicy for Recordings and PhotographyPage 21 of 25

NHS UnclassifiedRights Act including deprivationthe management ofphotography andrecording equally,irrespective of equalitygroupYou will need to continue to a full Equality Impact Assessment if the followinghave been highlighted:• A negative impact and• No consultation (this excludes any policies which have been identified asnot requiring consultation).8. If there is no evidence that thepolicy promotes equality, equalopportunities or improvedrelations - could it be adapted sothat it does? How?No. This policy is intended to ensure that theTrust deals with recordings consistently and inaccordance with the requirements of extantlegislation.LEAD PERSON DECLARATION (individual completing the assessment)FULL IMPACT ASSESSMENT REQUIRED? Yes NoSIGNED BY LEAD PERSON: ……………………………………………………………………NAME: Kim BellisDATE: 1 June 2012Comments: NoneEQUALITY AND DIVERSITY LEAD/EIA SUB-GROUP MEMBER DECLARATIONFULL IMPACT ASSESSMENT REQUIRED? Yes NoSIGNED BY E&D LEAD/EIA SUB-GROUP MEMBER: ………………………………………NAME: ………………………………………………………………Comments:Keep one copy and send a copy to:The Human Resources Team,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Lamorna House,Penventinne Lane, Truro, Cornwall, TR1 3LJThey will arrange for a summary of the results to be published on the Trust’s web site.Policy for Recordings and PhotographyPage 22 of 25