Photographing Injuries in the Acute Care Setting: Development and Evaluation of a Standardized Protocol for Research, Forensics, and Clinical Practice

Academic Emergency Medicine, Volume 23, Issue 5, pages 653–659, May 2016

Photographing injuries in the acute setting allows for improved documentation as well as assessment by clinicians and others who have not personally examined a patient. This tool is important, particularly for telemedicine, tracking of wound healing, the evaluation of potential abuse, and injury research. Despite this, protocols to ensure standardization of photography in clinical practice, forensics, or research have not been published. In preparation for a study of injury patterns in elder abuse and geriatric falls, our goal was to develop and evaluate a protocol for standardized photography of injuries that may be broadly applied.

We conducted a literature review for techniques and standards in medical, forensic, and legal photography. We developed a novel protocol describing types of photographs and body positioning for eight body regions, including instructional diagrams. We revised it iteratively in consultation with experts in medical photography; forensics; and elder, child, and domestic abuse. The resulting protocol requires a minimum of four photos of each injury at multiple distances with and without a ruler/color guide. To evaluate the protocol’s efficacy, multiple research assistants without previous photography experience photographed injuries from a convenience sample of elderly patients presenting to a single large, urban, academic emergency department. A selection of these patients’ images were then evaluated in a blinded fashion by four nontreating emergency medicine physicians and the inter­rater reliability between these physicians was calculated.

Among the 131 injuries, from 53 patients, photographed by 18 photographers using this protocol, photographs of 25 injuries (10 bruises, seven lacerations, and eight abrasions) were used to assess characterization of the injury. Physicians’ characterizations of the injuries were reliable for the size of the injury (κ = 0.91, 95% confidence interval [CI] = 0.77 to 1.00), side of the body (κ = 0.97, 95% CI = 0.88 to 1.00), precise location of the injury (κ = 0.74, 95% CI = 0.63 = 0.81), and type of abrasion (κ = 0.76, 95% CI = 0.45 to 1.00). The exact shape of the injury (κ = 0.44, 95% CI = 0.17 to 0.51), and the primary color of bruises (κ = 0.37, 95% CI = 0.25 to 0.48) were not as reliably characterized.


Standardizing the documentation of injuries with photographs for clinical and research assessment can be conducted by nonprofessional photographers. A photography protocol will ensure that this important mechanism for documentation is optimized.

Personal comment: In TEREM, we began using a photography tool quite a few years ago. An android app was initially developed than handled the image taking, and then deleted the image on the phone once it was sent to the capturing server. With modified software, the same app could have supported DICOM, although this has not yet been done. There is NO question that a single photograph can make all the difference in deciding on rashes, lacerations, gross findings on exam and more. Once again, my advice is to have such a module be incorporated into every EHR. As protocols for standardization come around, these can be added. But even simple photography using a smartphone is very powerful.