The move toward electronic medical records; follow the audit trail
More and more, hospitals, clinics, and doctors’ offices are making the move to an all electronic medical record (EMR). The benefits of EMR include a reduction in medication errors caused by doctors’ notoriously poor hand writing. The goal of reducing medication errors is laudable; however, what stops a less-than scrupulous health care provider from going in and changing critical information in the EMR to cover up a medical mistake that causes a patient to be injured or worse yet die? The answers may lie in what is called the audit trail. In EMR programs the audit trail keeps track of when charting is done and who does the charting. If a health care provider goes in at a later time and changes the medical records, the audit trail will list when the change was made and who made the change. This information can be critically important when representing a person injured or killed by medical negligence especially when the records are completely inconsistent with what our client or family says happened. For example, when the records says “patient refused diagnostic test” and the patient or family say that the diagnostic test was never even offered.
At McKeen & Associates, P.C. we have access to computer experts who can assist us in accessing audit trails to see if, when, and how EMR have been altered. Hospitals and doctors’ offices fight us tooth and nail on these issues, which is what tells us we are on the right track.