Posted January 2, 2023

The most objective evidence one can provide to a case is an Audit Trail Investigation of the Electronic Medical Record (EMR). This information can identify down to the second who was in the chart and what exactly they did in the chart. An Audit Trail Investigation can quickly identify many issues contained within an EMR.

First of all, let’s answer the question: what is an audit trail. In healthcare, the Health Information Portability and Accoutability Act (HIPAA) requires healthcare facilities to have an audit trail of the different electronic medical record software systems. The EMR audit trail is a file that logs all points of access of a patient EMR system. This include any actions to modify, view, print or amend the record by replacing or adding new data within the EMR.

Secondly, an audit trail can confirm data integrity and highlight missing records and/or records tampering. The way that we confirm data integrity is that we compare the audit trail to the actual medical records to show that all the records that should have been received were received. If an audit trail has entries for records that are missing, we can make a request for additional discovery and be very specific. Conversely, if an audit trail shows activity that is unusual and we compare it against the records, it may indicate that there was tampering.

Thirdly, let’s discuss how an audit trail can show exactly what happened in a medical record. When a user who has access to an EMR takes any type of action, it registers in the audit trail as occurring. For instance, when a healthcare professional is caring for a patient and they chart on the patient in the Flowsheets, it logs their entry, and creates a timestamp, down to the second. If the patient has an event and the caregiver returns to their prior entry and modifies that entry, we can see when both actions happen: when the original entry was recorded and when the modification occurred. In addition, even if someone only views the EMR, it also documents that, which could potentially identify additional at fault parties or, at a minimum, give additional insight from a witness to the event that may not have been obvious originally.

There is very powerful information contained within an Audit Trail. These are just a few examples of how an Audit Trail Investigation of an EMR can help a case. Now that you have an idea what information an Audit Trail Investigation can bring to your case, let’s unveil the data that is hidden within your cases. Call our firm, Cerbry Consulting, LLC, at (602) 290-6554.