I do not profess to be an expert in the complexities of metadata in an electronic medical record (EMR). In simple terms, it is analogous to leaving footprints in the sand; although these do not wash away with high tide. In fact, the simple act of logging in and out of an electronic medical chart, and more significantly, viewing and creating records, is indelible. Most health care providers never even consider the impact of logging on and viewing a medical chart in their daily practice.
The metadata can be compiled into an audit trail that shows the date, time and user who accessed a patient’s chart. It even shows whether the user created or added to an existing record. Consequently, audit trails from a patient’s EMR can either support or discredit the testimony of medical providers during medical malpractice litigation. Plaintiffs’ attorneys are becoming more sophisticated and now ask for these audit trails as part of their standard discovery requests.
Continue Reading Audit Trails: Pitfalls of Electronic Medical Records, Part III
