Document Title /

Visual Imaging and Audio Recording Policy

Reference Number / NTW(O)45
Lead Officer /

Lisa Quinn,

Executive Director of Performance and Assurance

Author(s)
(name and designation) / Sue Proud
Information Governance Manager
Ratified by /

Trust-wide Policy Group

Date ratified /

June 2015

Implementation Date / June 2015
Date of full implementation /
June 2015
Review Date /
June 2018
Version number /
V06.1

Review and Amendment Log

/

Version

/
Type of Change
/
Date
/
Description of Change

V06

/

Annual Review

/
Jun 15
/
  • Updates to Sections 5 and 10

V06.1

/

Update

/
Nov 16
/
  • Inclusion of VIA-PGN-02 – Recording Consultations

This Policy supersedes the following document which must now be destroyed:

Document Number / Title
NTW(O)45–V06 / Visual Imaging and Audio Recording Policy

Visual Imaging and Audio Recording Policy

Section / Contents / Page No.
1 / Introduction / 1
2 / Purpose / 1
3 / Duties, Accountability and Responsibilities / 2
4 / Definition of Terms / 2
5 / Procedure/Process / 3
6 / Identification of Stakeholders / 9
7 / Training / 9
8 / Implementation / 9
9 / Fair Blame / 9
10 / Fraud, Bribery and Corruption / 10
11 / Monitoring / 10
12 / Associated Documents / 10
13 / References / 11
Standard Appendices – attached to policy
A / Equality Analysis Screening Toolkit / 12
B / Training Checklist and Training Needs Analysis / 14
C / Audit Monitoring Tool / 16
D / Policy Notification Record Sheet- click here
Appendices – listed separate to Policy
1 / Consent Form for Audio Visual Recording
Practice Guidance Note – listed separate to Policy
PGN No. / Description / Issue / Date Issued / Review Date
VIA-PGN-01 / PGN for taking patients photographs within inpatient settings to maintain patient safety / V02-Issue 2 / Oct 16 / June 18
VIA-PGN-02 / Visual/Audio Recording of a Clinical Consultation / V01-Issue 1 / Nov 16 / Nov 19

1Introduction

1.1This Policy outlines staff responsibilities towards service users, other staff and members of the public with regard to the use of visual and audio recordings and to ensure that all recording that takes place is done:

  • For a clear purpose
  • With full consent of all service users, staff and the public
  • With appropriate control of use, storage and transportation

2Purpose

2.1To prevent unauthorised disclosure of person identifiable data (PID) held by the Trust.

2.2Visual and audio recording can be beneficial in clinical care, to assist in treatment, to record changes, for teaching purposes and the first priority must be to protect the interests and well-being of individual service users and to keep information about them confidential.

2.3Any person undertaking recording of a service user does so on the understanding that all visual images and audio recording produced will be regarded as medical records. They are therefore entitled to the same degree of protection and confidentiality as written medical records giving regard to the principles of the Data Protection Act 1998. (See Management of Records Policy - NTW(O)09).

  • ‘Recording’ includes video and audio recording and the taking of digital and photographic images for the purposes of treatment/assessment of service users, staff assessment/supervision, research, staff training and clinical audit.
  • The Policy does not refer to the taking of images for the purposes of Trust publicity, the recording of social events or stories conducted by the media. Consent for these purposes must be obtained via the Communications Department.
  • Health Professionals should always ensure that they make clear in advance to the service user the purpose(s) of the recording. Explicit consent for that purpose must be obtained from the service user prior to any recording. The recording must not be used for any other purpose without further consent from the service user. (See paragraph 6.2 for more detail on capacity to consent).

3Duties, Accountability and Responsibilities

  • Responsibility for implementation and compliance to this Policy lies with the Chief Executive and the Corporate Decisions Team
  • The Executive Director of Performance and Assurance as Senior Information Risk Owner (SIRO) has delegated responsibility from the Chief Executive
  • Group Directors must ensure ownership for implementation throughout their respective Directorates
  • Line Managers in collaboration with the Corporate Decisions Team and The Caldicott and Health Informatics Group are responsible for the day-to-day management and oversight of removable media used within their work areas to ensure this policy is followed
  • This Policy applies to all employees of the Trust, temporary staff, volunteers, contract and agency staff and any other persons working on behalf of the Trust

4 Definition of Terms

  • Visual Image: Any photographic image captured on a camera, video recorder or camcorder, including those integral to mobile phones etc
  • Audio recording: Any voice recording made on magnetic or digital media
  • Mental Capacity: The ability to make informed decisions for oneself
  • Digital recording: Electronically held recordings, both visual and audio
  • NHS Records Management Code of Conduct: A Code of Conduct issued by the Department of Health, which includes in Part 2, the NHS Retention of Records Schedule
  • Information Commissioner: Appointed by the Government to regulate information related legislation in the UK, including the Data Protection Act 1998, and the Freedom of Information Act 2000
  • Encryption: Encryption is specialist software that uses a complex set of mathematical algorithms and encryption keys to scramble data. Where the required software and encryption keys are available, data can be read as normal. However, without the software and keys, information is unusable
  • Video Conferencing: Video conferencing is a communication medium involving a computer, video camera, and network connection (an intranet or the internet for example). It allows a connection combining both voice and picture between two or more people. This allows meetings in a face-to-face format that eliminates the necessity of travel

5Procedure/Process

5.1Recordings made for Clinical Care

  • There must be a fully justifiable purpose for the recording of a service user to be carried out
  • A Trust owned and approved digital device must be used. Use of equipment owned by staff is not permitted, including mobile phones
  • When recording a consultation, the service user’s explicit consent must be obtained by completing the Consent Form at Appendix 1 which describes why the recording is being made and how it will be used
  • Recordings made for clinical purposes form part of the medical record. When considering the disclosure of such recordings normal standards of confidentiality for medical records apply
  • Where recording is required as an integral part of a research project, this must be specifically included in the research protocol and consent must be considered within the application for ethical approval
  • A recording made in the course of treating or assessing a service user may not be used for any other purpose, without obtaining the service user’s explicit consent
  • No recording should compromise the service user’s privacy and dignity

  • Recordings made for training purposes form part of the clinical staff training record, and are not an element of the Medical Record. Such recordings should be held in accordance with the guidelines in the NHS Records Management Code of Practice and retention schedule
  • Trust owned Blackberries must not be used to take photographs of people

5.2Approval to Record

  • Within specific services, the principle to use recording must be approved by the Team Manager/Supervisor or Head of Service, appropriate to the purpose of the recording
  • In all cases the person responsible for the recording must complete the Checklist on the Consent Form (See Appendix 1)
  • The service user must sign the Consent Form and it must be countersigned by the relevant clinician
  • A copy should be made of the consent form and given to theservice user to keep for reference. The original should be filed in the medical record
  • Where disability or illness prevents a service user from giving informed consent or where the service user lacks capacity, normal protocols should be observed. If necessary advice may be obtained on consent issues from the Caldicott Lead in Clinical Governance. A note should be recorded in the medical record of the factors taken into account in assessing the service user’s capacity
  • Where group work is being recorded the consent of all individual participants must be obtained
  • Where children who lack the understanding to consent are to be recorded, permission must be obtained from a parent or person with parental responsibility. People agreeing to recordings on behalf of others must be given the same rights and information as service users acting on their own behalf. Children under 16 who have the capacity and understanding to consent to recording may do so. A note should be made in the medical record of the factors taken into account in assessing the child’s capacity. If a child is not willing for recording to be carried out, their wishes must be respected, regardless of the consent of a person with parental responsibility
  • Once consent has been obtained consideration should be given as to whether the service user may require a period to reflect and possibly reconsider before recording actually takes place. Service users must know that they are free to stop the recording at any time and that they are entitled to view or listen to it if they wish, before deciding whether to give consent to its use. If the service user decides that they are not happy for any recording to be used, it must be destroyed. Where this forms part of the health record application must be made to the Health Records Department via the Subject Access Procedure, in accordance with the Data Protection Act 1998

5.3 Video Conferencing

  • Video Conferencing will not normally be recorded but minutes of the meeting should be made if a record of proceedings is required. If a video or audio recording is to made, participants should be made aware. If Video Conferencing is used for meetings involving Clinical cases, explicit consent of the service users must be obtained and recorded in the medical records
  • Security in the room containing the Video Conferencing equipment must be observed at all times. A notice to this effect should be displayed prominently. Additionally, a sign should be attached to the door warning of the presence of recording equipment within the room

5.4 Digital Recording

  • Digital recordings are easier to copy, manipulate and distribute than traditional recording
  • Where digital photography is to be used to record images of service users, due care must be given before the start of the project to ensure that the quality of the image is adequate for its purpose
  • Images of service users must not be taken off Trust premises unless encrypted on suitable portable media, (such as an encrypted laptop or encrypted USB memory stick), NORmust they be transferred to staff’s own personal computers and must be stored securely at all times. Advice may be sought from the Information Governance Team

5.5Storage and Retention

  • Traditional film processing, analogue voice and VHS is not permitted
  • Patient related recordings, under the requirements of the Data Protection Act, must be kept only for as long as the purpose for which they were obtained (see below) and must be available for disclosure to the patient if requested
  • Recordings taken for assessment or treatment of patients should be destroyed as confidential waste at the end of the agreed period as specified on the Consent Form, and within the retention guidelines set out below
  • If the recording forms part of the medical history of the patient the following will give guidance on the minimumretention period
  • Mental Health Records must be kept for 20 years after no further treatment considered necessary,however,asthe NHS Records Management Code of Practice states that Clinical Psychology records are set at a retention period of 30 years the Trust will retain all Mental Health and Clinical Psychology Records for a period of 30 years OR 8 years after service user’s death except Learning Disability records which will be retainedfor 10years after death
  • Counselling records 30 years
  • Photographic records 30 years
  • Child and Adolescent 30 years
  • Full NHS retention guidelines can be found at:
  • When considering storage of images on magnetic and digital media, staff should be aware of shelf life, and make every effort to ensure that clinical data is not corrupted or damaged. Where necessary an additional copy should be made as a backup. Additional copies must be stored securely on Trust premises
  • Still photographs should be stored as a hard copy in the medical record, and the image deleted from the equipment
  • Recordings made for assessment or treatment must be referenced within the service user’s medical record stating the date(s) when the recording had taken place and the whereabouts of the recording
  • An entry should be made in the client’s medical record (on the reverse of the Consent Form) each time the recording is accessed. The entry should state the date the recording was accessed, by whom and for what purpose. This will be used to verify compliance with the terms of the service user’s consent
  • Depending on the medium, recordings should be kept where possible with the service user’s medical records, and recorded on RiO in accordance with procedure (See PGN). For example, a hard copy of photographs taken for the assessment or treatment should be filed within the service user’s medical record in the secure pouch designed for this purpose
  • Other patient recordings must be kept systematically and securely and there must be an effective tracing system to link the recordings to the correct records
  • Images of service users must not be left on the camera. Staff who share digital equipment are professionally accountable for those images and responsible for erasing images from the camera as soon as the images are completed and before passing equipment to colleagues
  • Staff must not use their own personal photographic equipment for taking clinical images, including mobile phones
  • Cameras containing images must not be transported off Trust premises. Images may be transferred to a fully encrypted device such as an encrypted laptop. If this is not an option practically, the risk must be assessed and recorded in the departmental Risk Register, and appropriate Executive Director approval obtained. The NHS national directive states that Board level approval must be obtained
  • Equipment and recordings must be stored securely at all times on Trust premises
  • All recordings both audio and visual, when due for destruction must be treated in a confidential manner. Advice on how to securely destroy all forms of magnetic media can be found on the Trust Intranet at:

Alternatively advice can be sought from the Information Governance Team at:

  • It is not permitted to lend, sell, hire or provide for research any recordings or images to external bodies OR remove them permanently from Trust premises without permission from the Trust Board
  • Recordings undertaken to provide evidence of staff training where the organisation is outside the Trust (for example, the University) will be covered by the provider’s Policies and Protocols. Staff should ensure explicit consent of the patient is obtained. Patients must be aware of the purpose of the recording and the fact that the recording will be disclosed to and retained by the external body. If in any doubt, advice should be sought prior to any recording, from the Trust’s Caldicott Guardian or Information Governance Team

5.6Recordings by Service Users/Relatives/Carers

  • Occasions may arise when the service user, their relative or carer may wish to record a consultation or conversation with a health professional;
  • There should be no restrictions on the recording taking place provided that:
  • The recording is done openly and honestly
  • The recording process itself does not interfere with the consultation
  • The provision to the service user of such a record will not adversely affect their treatment
  • If it is a relative/carer who wishes to make the recording, then the full consent of the service user must be obtained and recorded in the service user’s health records
  • If the service user is unable to consent then the recording cannot take place until a capacity assessment is carried out
  • A note should be made in the service user’s medical record that a particular consultation or conversation was recorded
  • The service user/relative and should be reminded of the confidential nature of the recording and the need to ensure that it is their responsibility to keep it secure
  • No recordings by service user, relative or carer should be done within a ward/department setting. Guidance should be sought from the Information Governance Department

6Identification ofStakeholders

6.1This is an existing Policy which has only minor changes that do not relate to operational and/or clinical practice therefore did not require a full Trust-wide consultation process.

7Training

7.1 Training for this Policy is delivered where necessary by the Information Governance Team to the IAO’s and IAA’s.

7.2Where additional training is required it is the responsibility of both managers and staff to ensure that this is undertaken and that attendance is verified and recorded.

8Implementation

8.1Taking into consideration all the implications associated with this Policy, it is considered that a target date of June, 2015is achievable for the contents to be implemented across the Trust.

8.2This will be monitored by the Trust-wide Policy Group during the review process. If at any stage there is an indication that the target date cannot be met, then the Group will consider the implementation of an Action Plan.

9Fair Blame

9.1The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

10Fraud, Bribery and Corruption

10.1In accordance with the Trust’s NTW(O)23 – Fraud, Bribery and Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.