When an attorney asks me why he/she should request an audit trail and what it can potentially reveal, I have to reel in my word vomit about audit trails and how they will really rock your world!
But really, audit trails are the metadata that can authenticate the patient’s medical record. With an EMR, the amount of data produced far exceeds that of the old bedside trifold chart. The EMR produces overwhelming amounts of data. We can see who was in the medical record, when, at what station and so much more!
Think about it, your case has a critical window of events. Once that timeline is established from the medical records, you can utilize the audit trail to authenticate your medical records. Use the audit trail to verify entry dates, when a note was written, signed, viewed, etc.
Start by getting your audit trail set-up in excel were the data can quickly be sorted for key words, people, etc.
Next, identify signed documents in the medical record during your key timeline and verify their status in the audit trail. Was there an edit made after a critical event?
Then move onto personnel. Who was caring for the patient during that timeline? When did that individual access the medical record and from where? For example, the nurse documents she remained in the room to provide support to a patient while waiting for the rapid response to arrive. However, it is noted in the audit trail that the nurse was logged into a computer down the hall during the event. What does this mean? Is it helpful? That all depends. However, it needs to be noted as an anomaly and looked into if it is a key event in the case.
But, a word of caution, audit trails cannot be used as a stand alone document. They require explanation and need to be used in conjunction with the medical record by someone who understands the information being presented in the audit trail. An audit trail by itself is useless. However, when used appropriately, it can highlight new requests for production, additional discovery and create new lines of questioning at deposition.
MD Medical Consultant can provide:
- Review of Case Validity and Value
- Medical Summary Reports
- Interpretation of Meaning, or Lack thereof, of Medical Reports & Records
- IME Observation & Rebuttal Reports
- Answers to Specific Medical Questions in Cases
- Standard of Care Reviews
- Medical Case Coordination
- Liaison to Treating Doctors
- Assessment of Causation
- Referral to Appropriate Medical Experts
- Determination of Future Medical Care and Costs
- Medical Research and Delivery of Medical Journal Articles
- Facilitation of Communication with Clients, Families, Professionals and Service & Governmental Agencies
- Independent Record Reviews
- Help Developing Medical Theories
- Deposition & Court Assistance-Table-side or Question Preparation
