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What you can learn from medical record audit trails

Audit trails should be programmed and preserved to promote transparency

Many Americans from all political persuasions looked forward to the end of the political advertising in November 2020. But because of questions regarding election integrity and electronic vote counting, the outcome of the presidential election remains unsettled.

As I’ve read and watched various news stories, I couldn’t help but think about the audit trail feature that’s built into electronic medical record software.

Medical record audit trails provide a treasure trove of information that can be useful in medical malpractice cases, provided that the attorney knows what to ask for. Sometimes, though, even after asking for the correct information, hospitals try to produce a pile of useless junk and just hope you’ll go away.

At a minimum, a properly constituted audit trail of an electronic medical record provides the date, time, username, and type of activity performed for each time that the medical record was accessed. Think about the utility of this information.

An audit trail may verify or rebut physician testimony about being in the hospital a certain time or whether a radiology report, lab result, or nursing note was reviewed. Additionally, the type of activity performed is the key element that should be included in any audit trail. It will identify any entry, modification, or deletion that occurred.

Because of federal government incentives, most hospitals and facilities now use electronic medical records. So do most physician offices, for that matter. One of the challenges in medical malpractice litigation is that electronic medical records appear and are formatted differently in their native state (within the electronic medical record software) than in the printed or electronic PDF form that’s produced in response to discovery and a lawsuit.

I can’t begin to count the number of times when we’ve ordered medical records for a client pre-suit, only to have a hospital later produce additional highly relevant pages after the lawsuit is filed. Obtaining the audit trail can help to verify that the entire medical record was produced and whether those additional records were accidentally not produced or generated after the fact.

If you’ve been seriously injured because of poor hospital or medical care in Texas, then contact a top-rated experienced Houston, Texas medical malpractice lawyer to discuss your potential case. Attorneys with skills in this unique and complex area of the law understand audit trails and what they can do to help with investigating a medical negligence case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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