From time to time, potential and current clients of Painter Law Firm express concern about the possibility of their medical records being—excuse the pun—doctored.
Before electronic medical records became commonplace, it was often hard to tell whether an entry or even an entire document had been fabricated. If a nurse, doctor, or risk manager wanted to slip in a new page or entry, they might be able to get away with it.
I remember going to hospitals years ago to examine the original medical records to look for differences in ink color or other factors that might suggest a forgery. In some cases, we even went so far as to hire a forensic document or handwriting expert.
These days, there is a different forensic tool available to medical malpractice attorneys who are in the know. It’s called an audit trail. And as a former hospital administrator and experienced Houston, Texas medical malpractice attorney, it’s probably my favorite thing about electronic medical records.
In short, audit trails are a part of electronic medical record software and track all kinds of information on every entry and modification to the patient’s medical record. Useful things that can be uncovered by obtaining the audit trail include:
• The user name or ID and location of every person who made an entry into the medical record.
• Any modifications made to the medical record, including the user name or ID and what was modified.
• How long a medical record page or radiology image was kept open for viewing by the user.
In numerous Texas medical malpractice lawsuits, I’ve conducted formal discovery to obtain audit trails, which allowed me to investigate or verify different issues.
In a recent Waco case, for example, a surgeon testified at deposition that he had carefully reviewed radiology images of the plaintiff before making a questionable decision to proceed with a dangerous surgical procedure. I doubted his story and used the hospital audit trail to uncover that his so-called detailed review of a CT scan only lasted two or three minutes. In other cases, I obtained audit trails that uncovered the fact that surgeons modified their operative report several times up to a month after the surgery in question.
It’s always good for the plaintiff to know whether a physician or nurse modified a medical record after there was a bad outcome. Some healthcare providers give in to the temptation to try to cover their backside by adding notes after the fact. I’ve seen numerous cases, for instance, where surgeons went back to the patient’s medical record after a botched procedure to document in great detail how they had gone over with the patient the risk of the exact bad thing that happened before even taking them into the operating room.
While audit trails can be a treasure trove of information for plaintiffs, they don’t prevent physicians, surgeons, anesthesiologists, or nurses from documenting incorrect information in the medical record in the first place. This is another common complaint of patients and family members. I frequently go over record with our clients and hear comments like, “I never said that” or “That’s not what happened.”
The truth is, in my experience, some healthcare providers are a bit sloppy and inaccurate when it comes to their medical record documentation. This becomes easily apparent in what I call “chart creep.” That’s when a doctor or nurse makes a documentation mistake early in the hospital stay and other providers continue to repeat the same incorrect information throughout the patient’s future care.
This is a reason why think it’s important to re-tell your story each time you see a new physician or provider. I believe that providing information yourself helps reduce the risk of accidental documentation errors in hospital and physician medical records.
If you’ve been seriously injured as a result of poor medical or hospital care and have concerns about the accuracy of your medical records, you should consult a top-rated Texas medical malpractice attorney to help you investigate your potential case.