The electronic medical record (EMR) takes away the burden of deciphering a physician’s handwriting when working up medical cases. However there are many versions of software in use and they can all present their own set of issues when wading through repetitive documents to find that needle in the haystack. One advantage that the EMR allows us to identify is who entered what information, when they entered that information, if an addendum was made to that entry and from what work station those entries were made. This information can be very helpful in identifying timelines, late entries and fraudulent documentation. In order to obtain this information an “Audit Trail” can be requested in discovery. This document can be monumental in making or breaking a case. I have attached an article written by a colleague of mine, Michael Seaver, RN that discusses the audit trail. I thought you may find it helpful. This article is taken from the Summer 2018 Journal of Legal Nurse Consulting (JLNC), a publication of the American Association of Legal Nurse Consultants. This volume discusses other information related to the Electronic Health Record that you may find useful as well. To access the full journal or other JLNC volumes follow this link:
http://www.aalnc.org/page/the-journal-of-legal-nurse-consulting