Articles

As most providers know, an audit trail can reveal the events and activities relating to the documentation of patient care.  Specifically, the audit trail can show:

• Who accessed a patient’s records
• When the records were accessed and for how long
• What actions were taken
• The terminal or device used
• Any changes that were made to the records and by whom
• Internal communication between providers
• System alerts triggered by patient data
• Protocol or policy considerations used in connection with orders

Because of the valuable information that can be gleaned from the audit trail, plaintiffs’ attorneys in malpractice cases sometimes refer to it as a “goldmine.”  One “nugget” that is often not considered by providers is that the audit trail confirms what documentation was available at the time of care but not accessed or reviewed.  This can be powerful evidence in a malpractice case where the defendant physician/provider asserts they were unaware of a specific test result, radiographic study, etc.  If the audit trail demonstrates that the information was available to the provider for the encounter(s) in question, and they failed to review it, that could constitute negligence depending upon the circumstances in the particular case.

To better protect themselves, increase patient safety, and improve outcomes, providers should:

• Be thoroughly familiar with the EHR system being used, including where important information is located.
• Use standardized documentation processes.
• Review labs, tests, studies, reports, medications, allergies, and other information regardless of who ordered, requested, or documented them.
• Review nursing notes for patients receiving in-patient care.

For additional information, contact the Risk Education Department or a Claims Attorney.