Medical Record Audit Trails

Medical Record Audit Trails

In this video, we discuss medical record audit trails in the age of medical records that are electronic you need to have an audit trail to see if changes have been made to the medical records.

Years ago, we had a case when there were paper records.

And in that particular case, we had obtained a set of medical records before we filed a lawsuit for our client.

And the records that we obtained were about a thousand pages of records.

We then filed a lawsuit, and we requested another set or another copy of the hospital records.

The records that were provided to us were pretty much the same, except for about twenty pages that had been altered.

Those altered pages, were such that they added some key facts and they deleted some key facts. And they were essentially hand copied from the existing pages but some modifications were put in. So, obviously, the changes were made to try to cover up what happened to the patient in that particular case.

So the changes were subtle, but they were substantial when you looked at everything in total.

At trial, we admitted both sets of the records.

And I set them in front of the jury and said, you know, both of these records are the same except for about ten to twenty pages where the doctors at the hospital changed what was in the records.

I then asked a rhetorical question.

What would a hospital or doctor have to hide that would cause them to change the record?

And I asked another rhetorical question.

What if my client had never gotten the records before the lawsuit was filed? The doctors in the hospital would have gotten away with their lies.

In the modern age, you have electronic medical records, and there’s no way to tell what’s changed except for the fact that the law requires that all record keeping systems create an audit trail. So if you get an audit trail, you can figure out exactly through the help of an expert what has been changed.

And that expert can help you explain to the jury that, oh, here’s the page that were changed. Here’s the lines that were changed on what date and by what person.

The jury can draw a conclusion as to why they were changed, and who was benefited by the change. So basically, when someone wants to change a medical record, it’s to lie. It’s to cover up what truly happened. And through the use of an audit trail, you can uncover those lies.

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