Finding Valuable Evidence in Electronic Medical Records

by | Published on Mar 25, 2015 | EHR/EMR

Electronic health records and the information they contain are invaluable in medical malpractice cases. However, there are certain aspects of EHRs that make it difficult for an attorney to figure out all the relevant medical evidence.

  • The hard copy printouts of the medical records are dissimilar from the way providers view patient information and the way they work with the particular software. The entire information can be obtained only by looking at the original data that was used to generate the report.
  • EHRs are designed to provide certain information and that is the only data you get from the printout. The full extent of the patient’s treatment history is not available by just looking at the printout.
  • The accuracy and authenticity of the printout cannot be verified by viewing it.
  • The time shown on a medical record printout is unreliable. You have to find out what that time represents. Some EHR system software even allows the user to input any time of their choice.

A lawyer looking for medical evidence in a medical malpractice case have to look beyond the printed records and review the EHR system’s audit trails to arrive at the complete information. For instance, if time stamps associated with certain tests, treatments, procedures etc. need to be clarified, it can be done only via an audit trail review. It helps establish a clear time line regarding the care provided to a patient, and also clarify the provider of service and the time of service. Importantly, an audit trail provides information of the data inputs entered or changed by an EHR system user as well as the time the change was made. This makes it easy to identify deletions, alterations and tampering in the EHRs. This is significant with regard to medical malpractice litigation because you can find out whether a particular negative entry was made, altered or deleted after the discovery of an adverse outcome or after the litigation started.

Review of EHR data including audit trails may prove challenging to an attorney or lawyer, and here the service of a medical record review company will prove invaluable. Expert reviewers will know what software is being used, what information to look for and how to interpret an audit trail. They will help identify when a particular service was performed, the time it was reviewed, the person who reviewed it, and the time the attending physician reviewed the report. Hiring expert hands to perform the medical document review is worthwhile taking into consideration the valuable evidence that will be unearthed in minimum time and with total professionalism.

Discover our medical record review solutions and partner with us for your next case.

Related Posts

The Electronic Health Record – Its Medical and Legal Importance

The Electronic Health Record – Its Medical and Legal Importance

Whether to understand the type of care provided to the patient, for medical record review, for obtaining billing information, or for information exchange, electronic health records or EHRs are much more efficient and convenient that traditional paper records. One of...

The Electronic Health Record and Medical Negligence Concerns

The Electronic Health Record and Medical Negligence Concerns

Earlier, one of the major concerns when providing medical record review services was the illegible handwriting of physicians. The electronic health record was introduced and made mandatory with a view to improve the quality of care, reduce medical record errors, and...