In the world of paper charting, identifying different handwriting within a single entry, additional notations squeezed in or obviously added later, a late entry or even entries that are out of sequence may alert us to possible document tampering. Unfortunately, detecting tampering within a medical record has changed now that more facilities are utilizing electronic medical records (EMR). One tool that can assist in the assessment of tampering of an EMR is an audit trail.
There are many different software systems that provide medical facilities with EMR technology. A similarity they all have is an electronic log that tracks EVERY action within the record. Some people refer to this as an “electronic footprint.” Nevertheless, an audit trail provides a complete list of individuals who access an EMR. It provides a time stamp when any individual logs in or out of the record and what section of the record is accessed, regardless if a notation is ever made. The audit trail also records what additions, deletions or edits are completed.
This metadata may not be forthcoming, but hospitals are very familiar with it. These same audit logs assist facilities in detecting unauthorized access to patient information. They are also used to track compliance with regulatory and accreditation requirements. Audit reports, containing the basic information mentioned above, are required in the 2014 update of 45 CFR 170.210 (Standards for health information technology to protect electronic health information created, maintained, and exchanged).
When requesting an audit trail, you may also want to consider requesting the data dictionary to better understand the organization of files and the names, labels and/or descriptions utilized in the metadata.
When requesting an audit trail, you may also want to consider requesting the data dictionary to better understand the organization of files and the names, labels and/or descriptions utilized in the metadata.
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