Making Sense of the Electronic Medical Records with the Audit Trail

Continuity of care is paramount in patient healthcare. The goal is always to give the patient the best medical care while at the same time reduce medical errors. For the last 20 years hospitals and physicians have been using electronic health records (EHR).

Although the intent was noble, EHR has caused serious and even catastrophic injury and harm to patients because of poorly written software programs for healthcare providers. Sometimes the medical recording software does not allow for certain medical conditions, treatments and tests. In those cases, the medical providers simply use the drop down or other shortcut to comply with the entry requirements.

It used to be that narrative nursing notes would be important in providing details of patient care. But in most hospital settings, nurses simply use default screens on a computer to make their entries. Physicians often are not able to read the nurses’ remarks or notes. 

Even today, most hospitals have a mix of handwritten notes and electronic entries, which tend to be burdensome and very difficult to interpret. 

In the end the issue is compatibility of electronic health records. Many companies produce the software for hospital and outpatient medical care. Most of these programs are not integrated with other healthcare software. Some hospitals even use multiple software systems, which differ from department to department. For example, the emergency department may use a different program than the intensive care unit. The billing format would likewise not be integrated with the same software at some facilities.

The audit trail is a useful key for interpreting electronic medical records. The patient has a right to look at his or her actual screen shots of electronic medical records through a portal. As of 2003, the federal statute, 45 CFR §164.3165, mandates healthcare facilities to maintain the electronic record, including the audit trail for six years from the date of creation. 

The audit trail allows healthcare providers and others to match the entries with those who have accessed the patient’s medical records. The audit trail remains an essential tool of medical records. It is not just the back-up to medical records, but it contains the patient’s vital information. The audit trail may show amendments to the patient’s final medical records. For example, if a radiologist interpreted an MRI, the electronic health record would show the date and time the study was taken and the date it was interpreted. It also would show in the records the dictated interpretation by the radiologist. But the audit trail would also show who accessed the radiology films and when. The audit trail would show the name of the technician who may have logged into the system to review that MRI. It would also include the name of the person who viewed the record. 

In summary, the audit trail is a very useful back-up and tool to verify hospital record entries.  Given the increasing use of electronic health records, managing all of the data can be processed with the use of audit trail documents. 

It is a well-known fact that medical errors involve miscommunication between healthcare providers. This happens when the responsibility for a patient is passed off to another healthcare provider. The medical records serve as the resource to make sure that the correct patient information is provided to the next caregiver. When the electronic medical records fail to be accessible or complete, medical errors occur more frequently. In some instances, the failure to keep correct medical records leads to serious patient injuries and death to innocent individuals. These negligent acts can be eliminated with careful recordkeeping and the use of the audit trail.

Kreisman Law Offices has been handling birth injury cases, medical negligence cases and nursing home abuse injury cases for individuals and families who have been harmed, injured or died as a result of the carelessness or negligence of a medical provider for more than 37 years in and around Chicago, Cook County and its surrounding areas, including Winnetka, Antioch, Deerfield, Rolling Meadows, Chicago (Jackson Park), Justice, Round Lake Beach, Chicago (Lakeview), Tinley Park, Itasca, Calumet City, Westchester, Waukegan, Joliet, St. Charles and Geneva, Ill.

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