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UWHC,

Policies,Clinical,UWHC Clinical,UWHC-wide,Legal Affairs

Videotape Recording & Patient Photographs (4.15)

Videotape Recording & Patient Photographs (4.15) - Policies, Clinical, UWHC Clinical, UWHC-wide, Legal Affairs

4.15

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 1
Of 9

Title:
Videotape Recording and Patient
Photographs

I. PURPOSE

To establish processes for filming or taping in UWHC facilities except for images that are
an integral part of a medical or surgical procedure.

II. POLICY

A. General. "Filming" and "taping" means the monitoring, creating, recording, and/or
transmission of visual or auditory images using any media except for images that are an
integral part of a procedure (e.g., radiographic images, fundus photographs). Filming and/or
taping in UWHC facilities is necessary or desirable for a variety of reasons (e.g., facilitate
patient care, provide instruction to staff, conduct research, assist in internal quality
assurance processes, provide security surveillance, conduct marketing etc.).
B. Written Authorization Requirement.
1. Patient Privacy. Because of the potential for breaching patient privacy, except as
permitted by section IV of this Policy, written patient authorization is required prior
to taping and/or filming for the following purposes:
a. External Third Party. Filming and/or taping created by and on behalf of an
external third party, e.g., radio, television, law firm, etc.
b. Marketing and Fundraising. Filming and/or taping created on behalf of
UWHC for marketing, fundraising or similar purposes, whether created by a
third party or created internally.
c. Internal Purposes. Filming and/or taping that are to be used only for internal
organizational purposes such as quality assurance projects and/or staff
education including student training.
d. Research Purposes. Filming and/or taping by staff conducting research
projects.
*Note: Written patient authorization is not required in the following situations:
a) when staff film and/or tape for patient care or internal security

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 2
Of 9

Title:
Videotape Recording and Patient
Photographs

surveillance purposes; b) when film or tape is created for patient care
purpose, but may later be used for internal educational purposes.
2. Patient's Right to Limit/Revoke Written Authorization.
a. Except for security surveillance and as specified in section IV of this Policy,
patients have the right to request that taping or filming cease at any time.
Staff must honor a patient's request upon learning of such a request.
b. Patients have the right to revoke their authorization anytime prior to the
taping or filming being used as intended. Once the taping or filming has been
used as intended, revocations will be considered on a case-by-case basis by
the department responsible for creating and/or utilizing the filming or taping.
Patients must make their intentions to revoke their authorization in writing
through the Patient Relations Department. This section does not apply to
filming and/or taping that occurs for external third party purposes. UWHC
cannot control what happens to film and/or tape created by and on behalf of
these individuals/organizations.
C. Time and Manner. Filming and/or taping shall be conducted at a time and in a manner that
does not interfere with patient care or operations at UWHC. UWHC clinical or
administrative staff may stop any filming or taping if it interferes with patient care or
operations, or if it is not in compliance with this policy.
D. Property. Filming and taping made by or under the direction of hospital staff is the property
of UWHC and may not be transferred to a third party except as authorized by UWHC.
Filming and taping for external third party purposes remain the property of the
individual/organization creating the film and/or tape.
E. Storage. Except for still photographs taken for patient care purposes, filming and taping is
not made part of the medical record, except when it is authorized by UWHC Health
Information Management. Filming and taping must be filed and maintained in a secure and
confidential area by the department/unit requesting the filming or taping. The film and/or
tape (and any copies) must be destroyed consistent with UWHC policy #1.06, "Electronic
Media Handling, Destruction and Disposal" at a time when it is no longer needed for the
purpose in which it was created (e.g., quality assurance purpose complete).

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 3
Of 9

Title:
Videotape Recording and Patient
Photographs

F. Confidentiality.
1. Films, tapes, and other recording s that are the property of UWHC under this policy
are considered confidential.
2. Except for recordings under subsections IV(B)(1) and (5), such films, tapes, and
other recordings may be accessed by (see III(F)(5) for restrictions on releasing
copies):
a. UWHC staff and students for clinical care, quality assurance, research,
surveillance, or education purposes, but only to the extent necessary for
achieving those purposes, and only as permitted above;
b. As otherwise authorized for distribution to third parties for publication, and
distribution to the general public;
c. The patient or the patients legally authorized representative;
d. Other persons with the written authorization of the patient or the patient's
legally authorized representative;
e. As required by law.
3. Recordings under subsection IV(B)(1) may be accessed only (a) by the clinical staff
involved in the care of the patient and only to extent necessary to achieving the
purpose or (b) with the written permission of the UWHC Legal Department.
4. Recordings under subsection IV(B)(5) may be accessed only with the written
permission of the UWHC Legal Department.
5. Persons granted access to films, tapes, and other recording that are the property of
UWHC do not have the right to copies under this Policy. Copies are released on a
case-by-case basis with the approval of the UWHC Risk Management Department
or UWHC Legal Department. Requests should be submitted to the UWHC Risk
Management Department.
G. Use of Third Party Contractor. If an individual or organization is contracted by UWHC to
create or assist in creating a film or tape, and is not subject to UWHC confidentiality policy
(#4.13), that individual or organization must sign a confidentiality statement agreeing to
protect the patient's identity and confidential information. Please contact the legal
department for such confidentiality agreement.
H. Prohibitions on Filming and/or Taping.
1. Staff Personal Use. Staff may not engage in filming or taping a patient for personal
use unless requested and approved in writing by the patient and/or family or through
Patient Relations.

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 4
Of 9

Title:
Videotape Recording and Patient
Photographs

2. Patient (or Family or Friend) Use of Personal Recording Devices Patients and/or
their family or friends may utilize devices for filming or taping individuals or activities
in UWHC facilities only in a place and manner that does not risk filming or taping
staff or other patients and visitors. Such devices include, but are not limited to:
cameras, video recorders, cell phones, pen cameras, other small digital cameras,
voice recorders of any kind or any device that allows visual or auditory images to be
obtained and/or transmitted.

III. PROCEDURE

A. Obtaining Written Authorization. Written authorization must be obtained from the patient or
the patient's legally authorized representative in the following manner:
1. Third Party External and Marketing and Fundraising Purposes.
Public Affairs Department must be contacted to coordinate any filming and/or taping
for media, marketing, fundraising or similar external purposes. UWHC
"Authorization to use Image/Demographic Information in Public Communication"
form shall be utilized.
2. Internal Quality Assurance and/or Educational Purposes. UWHC "Authorization for
Taping and/or Filming (Education or Quality Assurance Purposes)" form must be
completed prior to any taping and/or filming created only for UWHC quality
assurance or education purposes. Forms shall be sent to Health Information
Services for temporary placement until such a time it will be scanned into the
electronic record.
3. Research Purposes. UWHC will accept the written authorization on any form
approved by a UW Health Sciences Institutional Review Board to tape and/or film a
UWHC patient. Alternatively, UWHC "Authorization for Taping and/or Filming
(Education or Quality Assurance Purposes)" may be used. Forms will be maintained
in the primary research file.
*Note: Neither the "Authorization for Taping and/or Filming (Education or Quality
Assurance Purposes)" nor the "Authorization to Use Image/Demographic
Information in Public Communication" forms noted above are intended to be part of
UWHC official medical record.
B. Use of Personal Recording Devices. Except as noted in section II.H.2. above, staff who
observe a patient, guest, or employee take a picture in a UWHC clinical setting, or transmit

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 5
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Title:
Videotape Recording and Patient
Photographs

or attempt to transmit a visual or auditory image must report the incident to their supervisor
who is responsible for informing the person that they must cease such activity or they will
be escorted off UWHC premises regardless of whether they have a clinical need to be at
UWHC. UWHC Security may be contacted if necessary to escort the individual off the
premises.

IV. USE OF VIDEO MONITORING/RECORDING OF ACTIVITIES IN PATIENT
ROOMS AND PATIENT AREAS.

A. Video monitoring/recording of activities in patient rooms and patient areas is permissible in
limited circumstances. This protocol details those circumstances. Video monitoring of
activities in patient rooms and patient areas is permitted in six situations. Such video
monitoring should be conducted in accordance with the procedures detailed in this protocol.
Note that this protocol does not apply to video monitoring that is incidental to procedures or
to video monitoring for security purposes in public areas.
B. The six situations where such video monitoring is permitted:
1. UNDISCLOSED CLINICAL MONITORING AND/OR RECORDING.
a. In appropriate cases, undisclosed video monitoring and /or recording of
activities in a patient room or other patient care area can be conducted as a
purely clinical endeavor for patient safety and to assist in diagnosis. This
monitoring and/or recording is not conducted for law enforcement purposes and
law enforcement personnel cannot be involved in the decision-making,
monitoring, or review of this monitoring. Due to legal restrictions on audio
monitoring, undisclosed clinical monitoring/recording must be limited to video
and not include audio monitoring/recording, unless the UWHC Legal
Department has determined that an exception permits audio monitoring/
recording and has given approval. One example of appropriate undisclosed
clinical monitoring/recording is for suspected Munchausens disease by proxy.
b. There are some very limited situations in which audio monitoring or
recording is permitted (e.g., pursuant to court order or during any time a
UWHC staff person is involved in the conversation and knows that the
conversation is being recorded). Approval of the UWHC legal department is
required for any undisclosed audio monitoring or recording, except under
IV.B.5.

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 6
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Title:
Videotape Recording and Patient
Photographs

c. Records of this monitoring are protected health information (PHI) but are
not considered part of the medical record. No entry shall be made in the
electronic or paper medical record regarding the monitoring/recording, unless
authorized by the UWHC Legal Department. The records of the monitoring
shall be maintained in a secure location approved by the UWHC Privacy
Officer and shall not be released without approval by the UWHC Legal
Department.
2. UNDISCLOSED LAW ENFORCEMENT MONITORING AND/OR
RECORDING.
a. Video monitoring and/or recording of activities in patient rooms and patient
areas can be conducted as a law enforcement endeavor with an appropriate
court order authorizing the activity. Law enforcement then controls the
monitoring and recording in accordance with the order. Law enforcement
monitoring can include audio monitoring if court authorized. The court order
should be reviewed by the UWHC Legal Department before the monitoring or
recording starts.
b. UWHC may permit its cameras and recording equipment to be used by law
enforcement, if such use is does not interfere with UWHC's needs.
3. DEPARTMENT OF CORRECTIONS (DOC) MONITORING AND/OR
RECORDING OF THE LOCKED DOC UNIT.
a. DOC conducts video monitoring/recording of persons in its custody while
they are in the locked DOC unit. This is conducted under DOC auspices and
UWHC has no role in it.
4. DISCLOSED VIDEO MONITORING AND/OR RECORDING WITH
CONSENT OF THE PATIENT OR THE PATIENT'S REPRESENTATIVE.
a. Video/audio monitoring and/or recording of a patient is permitted with the
written consent of the patient or the patient's representative. For example,
neurology has some rooms where they monitor for seizure activities. In
addition, monitoring/recording with the consent of the patient or the patient's
representative may be an option when there is a need to monitor behavior of
staff or visitors (other than the patient's representative) while they are in the
presence of the patient.
b. Consent for disclosed monitoring/recording must be documented using a
UWHC approved Consent Form for monitoring/recording.

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 7
Of 9

Title:
Videotape Recording and Patient
Photographs

i. When the monitoring/recording is for clinical care, education and/or
quality assurance, the authorization for media capture form (UWHC
#301045-DT) must be used.
ii. When the monitoring/recording is solely for research purposes, the
research consent form approved by the UW Institutional Review Board
(IRB) (or another IRB listed in or approved under UWHC Policy
#4.24) that includes permission for the monitoring/recording shall be
used. When the approved IRB waives documented consent or the
research form does not include such permission, the UWHC form
(UWHC # 301045-DT ) must be used. Undisclosed video
monitoring/recording for research purposes is not permitted in UWHC
patient rooms and patient care areas unless prior approval is obtained
from the UWHC Legal Department.
iii. When the monitoring/recording is not covered by (i) or (ii), the
UWHC Legal Department must be contacted and the form it approves
must be used.
5. VIDEO MONITORING AND/OR RECORDING WITHOUT WRITTEN
CONSENT OF THE PATIENT OR THE PATIENT'S REPRESENTATIVE.
a. Video monitoring is permitted as part of clinical care without written consent
in UWHC's ICUs by e-Care of Wisconsin in accordance with the e-Care
program. Any recording by e-Care must be approved under another part of
IV.B. When possible patients or their representatives will be given information
regarding the monitoring, but it is understood that some monitoring by e-Care
will be undisclosed when there is no one who can receive the information.
b. Video monitoring is permitted as part of clinical care without written consent
for purposes of constant observation in accordance with UWHC’s Tele-Sitting
Program. No recording will be performed as part of this program. When
possible, patients or their representatives will be notified of and given
information regarding the monitoring. A sign will be displayed on the door of
the patient room where video monitoring is occurring to provide notice that
monitoring is in progress. The patient’s right to privacy should be respected at
all times. The video monitoring should be placed into privacy mode during
certain activities including, but not limited to, personal hygiene and physician or
provider requests during rounds or examination.

POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 8
Of 9

Title:
Videotape Recording and Patient
Photographs

6. UWHC LEGAL DEPARTMENT APPROVAL.
a. In other situations, when the UWHC Legal Department has reviewed and
approved video monitoring and/or recording, it may be conducted in accordance
with such approval. The purpose of the review is to determine if there is some
legal basis for providing approval. Note the UWHC Legal Department does not
have special authority under the law to authorize such monitoring.
C. Additional procedures for video monitoring/recording of activities in patient rooms and patient
areas
1. Except for video monitoring or recording being conducted by law enforcement or
DOC, whenever there is video monitoring and recording in patient rooms and patient
care areas, there must be a UWHC staff person or other person authorized by UWHC
watching the video at all times it is on. The video monitoring and recording must be
stopped whenever it cannot be monitored.
2. Except for video monitoring or recording being conducted by law enforcement or
DOC, there must be a means for the person watching the video to promptly notify
clinical personnel when a potential intervention is required. Clinical personnel who are
in the immediate vicinity of the patient will determine whether intervention is required
and initiate any such interventions.
3. Except for video monitoring or recording being conducted by law enforcement or
DOC, any recording of the video monitoring should be kept in a secure location
approved by the UWHC Privacy Officer, used only for the purpose for which it was
recorded, and not be released to others, unless the UWHC Legal Department
approves the release, use or disclosure.
4. Except for video monitoring or recording being conducted by law enforcement or
DOC, law enforcement and DOC cannot be involved in video monitoring or recording
and cannot be permitted to see such monitoring or recording or be informed of the
results, except (a) when law enforcement or DOC are called upon to assist in
institutional security and such information is necessary to provide that assistance or (b)
with approval of the UWHC Legal Department.
5. The patient, patient's representatives, family, friends and visitor shall not be informed
that undisclosed monitoring is being considered or is being conducted.
6. Undisclosed video monitoring/recording shall not be mentioned in the electronic
medical record, unless such entry is approved by the UWHC Legal Department.


POLICY & PROCEDURE





Effective Date:
May 7, 2015

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
4.15

Original
 Revision

Page 9
Of 9

Title:
Videotape Recording and Patient
Photographs

V. FORMS

Authorization for Taping and/or Filming (Education or Quality Assurance Purposes)
Authorization to Use Image/Demographic Information in Public Communication

VI. COORDINATION

Sr. Management Sponsor: SVP and General Counsel
Author: Compliance and Privacy Officer

Approval committee: UW Health Clinical Policy Committee

VII. SIGNED BY:

Ronald Sliwinski
President and CEO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee