Hospitals are required by federal law to maintain an audit trail for electronic medical records. The audit trail (which is discoverable) tracks when a medical record was accessed and when additions or alterations were made to the record (by whom and when).
The audit trail can provide information that is not always accessible in other medical records. But at the same time, the EMR software itself may make it difficult to export that audit trail data.
And, even if you can export that data, the accuracy of an audit trail may be questionable due to the hospital’s ability to temporarily suspend the audit function, make deliberate additions or deletions to the record or even entirely delete the contents of the audit trail. Depending upon the security settings and habits at a given facility the EMR and corresponding audit trail may not completely or accurately depict the patient’s healthcare.
Every Certified Legal Nurse Consultant should be able to address the importance of the audit trail to attorney-clients in relevant legal nurse consultant jobs. That audit trail, when accurate and properly implemented, isn’t just the patient’s medical record, but is also a record of which healthcare providers accessed a patient’s chart, the entries they documented (or deleted) as well as the length of time they spent in that chart and even whether they accessed the chart without making an entry or alteration. HIPAA requires that a healthcare provider be able to generate an audit log.
You should also educate your attorney-client that different providers potentially have access to different views and corresponding data of the same EMR and should request copies of the screenshots available to the different defendants as well as those made available to the plaintiff. The attorney should also be aware of the dangers of automatic text as well as appropriate and inappropriate use of copy-and-paste (EMR Cloning) in the maintenance of a patient’s EMR. Also ask whether or not the defendant facility has a policy and procedure on the use of copy-and-paste in the EMR as well as inaccurate time-stamping.
The EMR can be a valuable tool for plaintiff attorneys in medical malpractice cases, but it can also provide defendants with the ability to obfuscate errors and omissions. It pays to understand the EMR (or to subcontract with a CLNC® consultant EMR expert) for legal nurse consultant jobs.
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P.S. Comment and share how you have used audit trails for electronic medical records in your legal nurse consultant jobs.