Photodocumentation and medicolegal evidence — formative SAQs

SAQ 1 — A patterned arm mark in a 4-month-old (10 marks)

A 4-month-old infant presents with coryza. On undressed examination you find a 2 cm ovoid bruise on the outer arm with what appears to be a fingertip pattern. The infant is not yet rolling independently. The emergency department is busy. [3] [5]

Questions

1. Describe how you would photographically document this injury at the bedside. (4 marks) [3]
2. Outline how you would label, store, and govern the images, and why personal-phone storage is unacceptable. (3 marks) [1] [9]
3. Describe how you would record this in the written note, including the fact-versus-opinion distinction. (3 marks) [10] [6]

Model answer

Photographic documentation (4). Photograph before any cleaning, dressing, or procedure because the finding is perishable. Capture the three-shot set defined by the standardised acute-care protocol: an orientation shot placing the bruise in anatomical context on the arm, a mid-range shot of the bruise in relation to landmarks, and a close-up with a scale (ruler or coin) held in the same plane as the injury with the camera perpendicular to the skin to avoid distortion. Use good lighting and repeat any blurred image. Transcribe the finding onto a body map with site, colour, shape, and measured size in two dimensions, and record the infant's developmental mobility in the same note. [3] [5]

Labelling, storage, and governance (3). Label each image immediately with the child's identity, the date, the time, and the anatomical site, and transfer it to the secure clinical imaging system or designated child-protection record. Storage must be access-controlled and audit-logged. Personal-phone or messaging-app storage is unacceptable because the image then lives outside the controlled record, its access is unlogged, its retention unmanaged, and its integrity open to challenge; it may also breach professional and privacy standards. The chain-of-custody principle requires that who accessed the images and when be recoverable. [1] [9]

Written record and fact versus opinion (3). Record the observed findings as fact: the size, site, colour, shape, and patterned quality of the bruise, and the developmental mobility of the infant. Quote the caregiver's mechanism verbatim as their account, not as established truth. Offer any interpretation — that the pattern is consistent with a fingertip grip, or that the mechanism is developmentally implausible — explicitly labelled as opinion with the reasoning. Disclose uncertainty and stay within your competence; you are a witness to fact, not the investigator. [10] [6]