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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Patient Identification Photo Capture
Policy Number: 1.59
Effective Date: July 1, 2016
To establish the standards that must be followed to photograph patient faces for identification
confirmation in the electronic medical record (EMR).
II. POLICY ELEMENTS
A. General. Patient photos are used to reduce errors in patient identification. The purpose of
patient identification photos is to improve the quality of patient care and interactions through
placing a patient’s picture in the electronic medical record. Having the photo in the EMR
allows for positive patient identification before treatment.
B. This policy only applies to patient facial identification photographs and not clinical
photographs. A patient photo does not replace the approved Patient Identification process
described in UW Health Clinical Policy 3.2.1-Patient Identification.
Equipment may be used for photography only if authorized by UW Health. The devices used
to capture the patient photograph must not store the image locally. Rather, there must be a file
transfer directly to the EMR and the secure blob server.
The use of a staff member’s cell phone/smart phone or other device to photograph a
patient for identification purposes is limited to the Haiku and Canto applications. All
devices must be encrypted and registered with the organization.
D. All patient photographs are permanently stored in the patient’s medical record and are
E. The patient’s picture will be viewable in multiple locations including the following:
ξ Patient Demographics (IFS)
ξ Patient Snapshot
ξ Appointment Desk
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ξ Identity Manager
A. The workflow for obtaining a patient photograph varies based on the clinical area and clinical
needs of the patient. When possible, the photograph should be taken at patient arrival, prior to
the patient being seen by the provider.
B. Identification photographs will be requested for all patients age 2 and older.
1. Prior to taking the photo, the staff member will verify the patient’s name and date of
2. For patients 18 or older, the staff member will also verify a photo ID prior to taking
the photograph. The following are acceptable forms of ID:
a. US or International Driver’s License
b. Government Issued Identification Card
c. Military ID
d. Passport or Passport Card
e. Tribal ID
f. Valid college ID from a US university/college (must include student name
g. Work ID (must include name and photo)
C. Quality of the Photograph
1. Photos will be cropped to show the patient’s head and remove any other people or
background images that are not needed for the patient photo.
2. Patients are allowed to wear head coverings as long as their face can be seen clearly
in the photograph for identification purposes.
3. If the patient normally wears prescription glasses, a hearing device, wig, or similar
articles, such item(s) should be worn for the picture.
D. Patient Refusals
1. The patient or their authorized representative may refuse having the patient’s
photograph taken for the electronic medical record.
2. When a patient declines, staff will upload a ‘Patient Refused’ image into the EMR.
Patients will be asked for a photograph again the next calendar year.
1. If a photograph cannot be taken due to time constraints, patient request, or clinical
situation, the photo will be left blank so the patient is prompted at the next visit.
2. Common sense and best judgment should be used when taking a picture. Pictures will
not be taken in the following circumstances:
a. If requesting a patient photo is creating anxiety or frustration, the photo may
be deferred to a later time.
b. Patients in an isolation status where personal protective equipment would be
necessary to take a photo.
c. Unconscious or unstable patients requiring lifesaving intervention.
d. Patients with significant, distorting facial trauma.
Note: It is appropriate to photograph a patient who has equipment in place (e.g. endotracheal
tube, feeding tube, etc.). The picture should be retaken when such equipment is removed or
F. Photo Frequency
1. Photos will be taken annually for children age 2-17 or upon request.
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2. Photos will be taken for adults age 18 and over every 5 years, upon request, or if
appearance has significantly changed.
G. No Photo ID (for patients 18 and older)
1. If the patient does not own an approved form of photo identification, the photo may
be taken and a status added to the record to indicate that the patient does not have a
2. If the patient owns an approved form of photo identification, but does not have it at
the time of the patient photograph, the photo will not be taken and the patient asked
to bring a photo to their next visit for photo capture.
3. When a patient turns 18, a photo ID will be verified when updating the photograph.
H. Patient and Photo Mismatch
1. If the patient has an identification photo in the EMR and presents looking very
different than the photo, staff should confirm patient identity and ask for a copy of
their photo ID. A second photo ID or additional information may be requested to
a. If it is the correct patient and the changes are significant, request that the
patient have their photo re-taken.
b. If you have reason to believe it is the wrong patient and suspect identity theft,
please do the following:
1. Create a new MRN and visit if possible to avoid overlaying patient
2. Contact clinical staff to inform them of the mismatch.
3. Send an email to the HIM – Identity team at HIM-
Identity@uwhealth.org with the patient details and a photo copy of
the photo ID if possible.
2. UW Health will not delay urgent/emergent care in order to verify patient identity.
UW Health Clinical Policy 3.2.1-Patient Identification
Sr. Management Sponsor: VP, Revenue Cycle
Author: Director of Registration and Technical Services
Approval Committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Next revision: 072019