In medical malpractice cases, there is one thing for sure: The medical records will be front and center for the parties, medical experts, and judge and jury to see. They’re so important because medical records are usually the only contemporaneous documentation of what happened in the healthcare at issue.
From handling countless Houston, Texas medical malpractice lawsuits, I can say that it’s pretty common to have situations where there is an issue with the medical records. It could be that a doctor or nurse noted false things that never happened. It could be that there’s a mysterious gap of time where there was no documentation. Or it could be that the records appear to have been faked, forged, or altered.
On a side note, these are some of the reasons that I recommend that patients and family members keep a real-time diary or journal of doctor visits, hospitalizations, prescriptions, orders, results, etc.
One of the investigative tools available to an experienced medical malpractice lawyer is the audit trail of electronic medical records. Under federal law, hospitals using electronic medical records have to comply with numerous audit trail requirements, as of April 20, 2005.
There’s a treasure trove of data available to attorneys with the competence and know-how to request and compel hospitals to produce audit trails. Experienced attorneys start by sending a preservation letter to hospitals, which requires them to preserve audit trail information so that it can be available during litigation.
Under federal law, at a minimum, an audit trail log must include:
• Date and time. The date and time that the patient’s medical record was entered and exited.
• Patient identification. Whether by name or number, the audit trail must be searchable by each individual patient.
• User identification. The audit trail has to keep track of each authorized user who accesses a patient record. This means, of course, that hospitals are required to issue unique access credentials to doctors and other hospital employees.
• Actions taken. The audit trail must keep track of the action taken by each user for a patient’s medical record. This includes actions like viewing the record and editing it in any way. Furthermore, the software will retain prior versions of the record before any alterations made.
• Data type. Audit trails identify the specific type of records that were accessed, like admission/billing/insurance information, physician notes, nursing notes, lab results, and radiology results.
As a former hospital administrator, I can tell you that many hospital leaders and healthcare providers don’t like the fact that patients and attorneys can look over their shoulders through audit trail information. Sometimes, though, that’s exactly what’s needed to get to the bottom of what actually happened.
I’ve used audit trail information to verify or disprove testimony from physicians or nurses about where they were during a key time in patient care and whether they were aware of important information like lab or radiology results.
If you or a loved one was seriously injured because of hospital or medical errors, then contact a top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.