Authenticating a medical record is an extremely difficult task to complete. Since the dawn of electronic medical records, federal policy has made this task significantly easier. Hospitals are required by law to maintain an audit trail for every electronic medical record. An audit trail is a way to show when a medical record was accessed, who accessed the medical record, who made any additions or alterations to the record, and when these additions or alterations were made. This federal requirement is a way to ensure that these medical records are not altered as a way to cover-up medical malpractice.
The HIPPA act of 1996 set-up a national standard for the maintenance of electronic medical records. HIPPA wanted to ensure that these electronic medical records could not be altered by the hospital without detection at a later date to cover-up incidents of medical malpractice. In addition to this requirement, HIPPA also stipulates that electronic medical records, including the audit trail, must be maintained by the health care provider for at least six years.
Your medical records should always be made available to you. Section 164.524 of title 45, Code of Federal Regulations states, in part:
(1) the individual shall have a right to obtain from such covered entity a copy of such information in an electronic format and, if the individual chooses, to direct the covered entity to transmit such copy directly to an entity or person designated by the individual, provided that any such choice is clear, conspicuous, and specific; and (2) notwithstanding paragraph (c)(4) of such section, any fee that the covered entity may impose for providing such individual with a copy of such information (or a summary or explanation of such information) if such copy (or summary or explanation) is in an electronic form shall not be greater than the entity’s labor costs in responding to the request for the copy (or summary or explanation).
When you hire a competent attorney, these records can be requested and obtained by the hired law firm. There are times when hospitals and doctors will delay access to these records or even attempt to prohibit their release. Once an attorney has been hired to represent your medical malpractice claim, if the health care provider refuses to produce these documents, your attorney can then have the court compel the doctor or hospital to produce all of these records in their entirety.
The audit trail provides information that is not accessible or discoverable in any other medical record. In a medical malpractice case, minutes can be the difference between life and death. A knowledgeable attorney will be able to use the information contained in the audit trail and to create a more complete story of the malpractice that was committed. The audit trail is a piece of information that, if used correctly, can bust a case wide-open.