Medical Record Audit Trails

I’m Katelyn Holub, an attorney focusing on personal injury law in northwest Indiana.

Welcome to Personal Injury Primer, where we break down the law into simple terms, provide legal tips, and discuss personal injury law topics.

In this episode, we discuss medical record audit trails.

Before the age of electronic medical records, there was no need to maintain a medical record audit trail.

Years ago we tried a medical negligence case where we ordered a copy of a patient’s hospital chart before we sued the hospital.

The chart was approximately a thousand pages long.

After we sued the hospital on behalf of our client we again requested the patient’s medical chart.

What was produced for us was a chart that was mostly the same, except 15 to 20 key pages had been modified.

These changed pages were critical to explaining the care given to the patient and all of the changes favored the hospital.

Obviously, the changes were made to cover up the medical negligence of the doctors who treated our client.

When we studied the changes in the handwritten pages, it was clear that the pages were copied over from the original chart.

But subtle changes were made and key facts were either eliminated from the new record, or key facts were added to the new record.

All the changes combined painted a very different picture of what happened to the patient during her stay at the defendant’s hospital.

The changes to the chart were essentially lies. What we had was a hospital lying about the treatment given to its patient.

At trial, we admitted both sets of the two charts into the record.

At closing, we set both sets on the table in front of the jury.

We pointed out that key pages had been changed. We asked the jury to look at those changes to key pages.

We then asked the jury a rhetorical question: Why would an above-board and trustworthy hospital need to alter the patient’s chart after being sued for being careless in treating their patient?

Then we asked a second rhetorical question: What if the plaintiff had not had the foresight to get a copy of her medical chart BEFORE filing a lawsuit?

The jury rendered a very favorable verdict for our client.

Without an audit trail, electronic records could be easily altered.

Without an audit trail, there would be no way to pinpoint changes made in a patient’s chart AFTER the treatment is rendered.

When there are changes made to handwritten documents, an attorney will sometimes call a handwriting expert as a witness.

To explain changes made to an electronic medical record, you need an audit trail expert

The audit trail expert can explain who accessed what portion of the electronic chart on what day and at what time. The expert can show exactly what was changed in the chart. The changes can be projected onto a large screen to show a jury precisely what was changed and when it was changed.

An audit trail takes away a medical negligence defendant’s ability to lie and cover their tracks.

I hope you found this information helpful. If you are a victim of someone’s carelessness, substandard medical care, product defect, work injury, or another personal injury, please call (219) 736-9700 with your questions. You can also learn more about us by visiting our website at DavidHolubLaw.com – while there, make sure you request a copy of our book “Fighting for Truth.”