By: Shelly Combs, BSN, RN, CEN, EMT-B, LNC

The phones are ringing off the hook and cases are rolling in faster than many can keep up with. Have you ever wondered how you can dig deeper into your medical malpractice cases? How could you find that document that could bust open the whole case and solidify your claim of malpractice or negligence? What if I told you that the document you wish you had, may not be in the printed record but there is a way to find it.

When a medical malpractice case arises, there is always question of injury. There is always question of negligence. There is always question of breech of duty and standard of care. Often when reviewing these cases in the past we find ourselves asking questions related to "red flag" type entries into the records. Things like, I wonder when Nurse Jane actually entered those vital signs or this note wasn't signed by Dr. Doe until 10 days after the event occurred, we wonder what happened in those 10 days. Often times, we would love to dig deeper and figure out what really happened during those critical times in the EMR and now we can.

What is an audit trail?

An EMR audit trail is the silent witness in your case or that fingerprint that ties everything back to the key suspect. They have been referred to as the breadcrumb trail of the EMR world. An audit trail is a collection of actionable data points that are created within the electronic medical record. The data points are typically actions that are completed within the EMR by providers and ancillary staff. Actions like Modify, Pend, Sign, View, Delete, Unchart, and Order. The audit trail answers four key questions:

• Who accessed the chart?
• What did they do during the time they accessed the chart?
• When did they do the actions listed while in the chart (specific timestamps)?
• Where were they (physical location such as workstation or laptop) when they accessed the chart?

While all of these items may not be beneficial in all cases, often times there is more information buried deeper in the chart than many attorneys realize.

How can an audit trail review help a medical malpractice case?

When medical records are requested for a case, only the finalized records are received. What does this mean? Well, for example, within the Epic charting system a provider can Pend a note. This is essentially the equivalent of saving the note to update or sign later. When you request records from an Epic case you would never know that Dr. Doe Pended his operative note for 7 hours before signing it. This would of course only be relevant if the injury was suspected to have occurred in the operating room or shortly after the procedure was complete. For example, if we were reviewing the medical records related to a possible missed surgical instrument case and Dr. Doe pended his note for 7 hours after the procedure completed, you better believe we would want to know what was in that pended note. Now the audit trail itself would not provide us with that information, however, we would be able to identify very specific discovery requests related to that Pended note.

Did you also know that a provider can Pend a note and NEVER sign it?? Crazy thought but it can and does happen and we would never know that pended note existed without an audit trail review.

Another benefit that is identified commonly is found within In Basket messages in Epic. These are essentially text messages within the EMR that providers can send to each other, often related to patient care. Here is another example: Nurse Jane charts that she notified Dr. Doe of the change in the patient's mental status at 0810. Her nursing documentation was entered at 0810. Dr. Doe states that Nurse Jane didn't notify him of the change in patient status until 1010. While reviewing the audit trail, we notice there is an In Basket message to Dr. Doe from Nurse Jane at 1008. This again brings a very specific discovery request related to that specific In Basket message so that we will know exactly what it says. When it is provided it verifies Dr. Doe's claim that he was not notified until 1010. This example could have easily gone the other way and verified Nurse Jane's version of events

Many EMR's also have Order Sets or Power Plans built into their system. These vary by facility but guess what . . . you can request what is within them for the facility you are reviewing. These Order Sets are essentially recommended orders based off of chief complaint. So, if a patient were to present with chest pain to the emergency room, an order set would populate for the physician that recommends ordering things like aspirin, an electrocardiogram, a chest x-ray and potentially lab work. But how is this helpful you may ask? Let's just say that the emergency room provider didn't order an electrocardiogram and said, "I must have forgotten" or "I'm sure I ordered it because it is my standard practice to order an EKG for a chest pain patient." If the order set for chest pain in his facility automatically populates this order and he used the order set, then he had to have intentionally "unchecked" the order from the list. All of these details can often be derived from review of the audit trail and additional discovery requests.

Audit Trail Review can also assist with overcoming defense arguments.

Have you been told by the opposing counsel that "the nurse (or doctor) was at the bedside and the medical team was doing everything they could for Mr. Doe but they were too busy to chart in real time." Guess what . . . through a user access audit review we can determine if those providers were in another patient's chart at the time in question or even identify if they were on a different unit at the time or even worse, at home during the time in question.

What about the defense claims that "my client must have just forgotten to save the information into the chart."? Well guess what . . . an audit trail can also shed some light on this claim as well by identifying if the provider ever attempted to enter the data. Did they view it? Did they delete it? Did they ever even enter that portion of the EMR in question.

Another fun fact is that any piece of medical equipment that connects to the internet/cloud in anyway can usually provide an audit trail. This means cardiac monitors, fetal monitoring systems, radiology systems etc, all have the possibility of providing an audit trail for review.

While this article focuses more on Epic audit trails (it is the most widely used EMR in the US) this is just the tip of the iceberg when it comes to EMR audit trails and their review. Any EMR that is utilized by a facility that receives payment from Medicaid or Medicare is required by law to have the ability to produce an audit trail.

EHR Audit Trails are up and coming in the medico-legal world. Why not learn about their abilities and benefits now and be part of the change in the way medical malpractice cases are managed?

This article was contributed by Shelly Combs, BSN, RN, CEN, EMT, CADS, LNC. Shelly provides audit trail services and can be reached at scombs@tsclegalnurseconsulting.com