Overcoming Unreliability of EHRs with the Audit Trail Feature

by | Published on Dec 28, 2015 | EHR/EMR

Medical record review for attorneys handling personal injury or mass tort cases focuses on gathering and summarizing the key components of the victim’s medical chart. Doctors and hospitals often maintain both paper and electronic records for their patients. Attorneys are usually assisted by a partnering medical record review company that would organize and index all the relevant medical records, prepare a chronology as well as a concise medical case summary.

What if there is a hint that the defendants may have tampered with the medical records? In this age of electronic medical records, the answer is an audit trail.

  • The audit trail gives a clear view of how the various records have been accessed or modified.
  • It is important that lawyers are familiar with this innovative concept because it is a very useful tool that will help authenticate records, prove liability and expose discovery abuse.
  • In a medical malpractice case, for example, a plaintiff who suspects that the medical charts have been altered by the defendant can always ask for the metadata or audit trail associated with the records produced by the defendant.
  • This audit trail can provide irrefutable proof whether the chart has been accessed or altered in any manner and by whom. It shows when each entry was made, and by whom. Additions, deletions and alterations can all be clearly identified. You will know who accessed the patient chart, when they accessed it and what they looked at. It would also tell you whether or not a doctor really looked at a test result.

A hospital, physician or other healthcare provider involved in litigation may not be able to present medical records as evidence without the underlying audit trail. For the medical records to be admissible, the provider must be able to demonstrate that the records were made “at or near the time of the entry,” and this is required by most state laws. This will not be possible without an audit trail.

With increase in the use of EMR systems and the growing complexity of electronic record keeping, medical litigators must clearly understand various electronic discovery issues. Attorneys handling medical malpractice, defective medical device, personal injury and mass tort lawsuits must be extra cautious and perform comprehensive electronic discovery to make sure that their clients’ medical chart accurately reflects the patient’s condition at the time of treatment.

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