LTC Survey Photo Log	

Facility:  __________________________________________________________________	Provider #:  ___________________________	
Survey #:  __________________________	Survey date(s):  ______________________________________	
Surveyor Names (Surveyor #): _____________________________________________________________________________________________________________	

Photograph in Series:  Generally speaking, each relevant object in the scene should appear in at least three photographs:  an overview, a mid- range photograph, and a close-up.
Overview:  The overview photograph should cover the entire scene to bring out the relationships between the objects. Leave measuring scales and labels out of the overview photograph.
Mid-Range:  The mid- range photograph shows a relevant object and its immediate surroundings.
Close-up:  Each close-up photograph shows a key detail clearly. Have a “standard” in the close-up photograph to indicate the actual size of what is being photographed.  Measure scales and labels may be added to the close-up photograph. Other standards include tape measures, coins, or a pencil.	

Photographs	
Photo #	Date	Time	Photographer
Surveyor/Surveyor #	Resident
Name or Identifier	Description  Scene/Object/Location	Consent*
(Check)	Staff witness **	Comments	

									

									

									

									

									
* Consent:  from Resident or surrogate		** Witness:  Member of facility nursing staff required to be present if photographing rectal, genital or breast areas