NEW SERVICE ALERT! Audit Trail Analysis
What is an Audit Trail?
An audit trail is the metadata record generated within an electronic health record system that tracks documentation activity behind the scenes.
While the visible medical record shows what was charted, the audit trail shows:
• When an entry was created
• When it was modified
• Who made the entry
• What time edits occurred
• Whether content was deleted
• When the chart was accessed
• Copy-forward activity in some systems
It is essentially the system’s activity log.
How does the Audit Trail Differ from the Medical Record?
The standard medical record displays the final version of documentation.
The audit trail captures the documentation history.
For example:
A nursing note may appear complete and timestamped at 14:05 in the chart.
The audit trail may show:
• The note was started at 18:42
• Edited at 19:10
• Finalized at 19:22
• Accessed the following day again and edited
That timing difference can matter depending on the clinical scenario and is important in litigation.
What Can an Audit Trail Assist with?
• Deposition preparation
• Timeline reconstruction
• Documentation sequencing review
• Credibility assessment
• Workflow evaluation
Common EHR Systems
- EPIC
- Cerner
- MediTech
- AllScripts
- PointClickCare
- Athena Health
- eClinicalWorks
- CureMD
- PACS
- Device Audit Trails, such as vital sign monitors and IV pumps, etc. (must be requested from the institution, usually within 180 days of the incident).
Basically, if an audit trail exists, I can analyze it.
You Might Need an Audit Trail if You are Reviewing a Case Where....
- Deposition testimony raises timing questions.
- The medical record sequence is difficult to follow
- There are questions about late or post-event entries
- Documentation appears repetitive and template-driven, with little to no patient-specific additions.
- Access history may be relevant
If you would like to discuss your specific case needs regarding audit trail analysis, feel free to email tiffany@evibasedconsults.com or schedule a consultation on the contact page.
