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Sidebar - The Chart Remembers · Statutes & Stethoscopes | Trial Lessons for Medical Injury Lawyers

• 0:03
  SPEAKER_00: This is Statute 10 Steps.
• 0:06
  SPEAKER_00: I'm Tracy Libertory.
• 0:08
  SPEAKER_00: Every episode I take one place where medicine and the courtroom collide and break down what actually works.
• 0:14
  SPEAKER_00: If you're a clinician who wants this work or an attorney who needs an expert who can hold up, you're in the right place.
• 0:20
  SPEAKER_00: Let's get into it.
• 0:25
  SPEAKER_00: Today, let me tell you about a note that looked perfect.
• 0:30
  SPEAKER_00: A resident in a nursing home developed a pressure injury on her sacrum.
• 0:35
  SPEAKER_00: By the time the family saw it, it was a stage four wound.
• 0:39
  SPEAKER_00: The chart on paper looked like the staff had done everything right.
• 0:44
  SPEAKER_00: Turned every two hours, skin checked every shift, heels floated, barrier cream applied.
• 0:48
  SPEAKER_00: Beautiful documentation.
• 0:50
  SPEAKER_00: Then the attorney asked for an audit trail.
• 0:54
  SPEAKER_00: And the audit trail showed that most of those repositioning entries for a full week were typed in on one afternoon.
• 1:05
  SPEAKER_00: Three days after the wound was discovered.
• 1:09
  SPEAKER_00: All by the same login in about 40 minutes.
• 1:12
  SPEAKER_00: Nobody had to argue about whether the resident was turned.
• 1:16
  SPEAKER_00: The question became why the chart said she was, and when someone decided to say so.
• 1:23
  SPEAKER_00: That is a very different case.
• 1:27
  SPEAKER_00: And that's what today is about.
• 1:29
  SPEAKER_00: Every electronic health record keeps two stories.
• 1:33
  SPEAKER_00: There's the note you see on the screen, and there's the record of who created it, when, from where, and what they changed or entered.
• 1:43
  SPEAKER_00: Clinicians mostly know the first story.
• 1:46
  SPEAKER_00: The second one is where a lot of cases are won and lost, and a very few nurses and doctors are ever taught how it works.
• 1:53
  SPEAKER_00: We know it exists in the background, we don't know much about it.
• 1:57
  SPEAKER_00: And many attorneys don't understand this either.
• 2:00
  SPEAKER_00: I've been asked many times about audit trails, and it is quite confusing and techie.
• 2:05
  SPEAKER_00: So let's start with the basics.
• 2:08
  SPEAKER_00: An audit trail, sometimes called an audit log or an access log, is the system's own record of activity.
• 2:16
  SPEAKER_00: Depending on the system and how the facility has it set up, it can show who opened a chart, who created an entry, and the exact date and time it was entered, the time the entry says the care happened, whether a note was edited, what the earlier version said, and who printed or viewed the record.
• 2:35
  SPEAKER_00: Some systems also show which workstation it was at, or which device was even used.
• 2:41
  SPEAKER_00: Those two times are the heart of it.
• 2:45
  SPEAKER_00: The time the care supposedly happened and the time someone actually typed it in as a note.
• 2:52
  SPEAKER_00: On a busy shift, those will never match perfectly.
• 2:56
  SPEAKER_00: A nurse gives a medication at nine and charts it at 9.20.
• 3:01
  SPEAKER_00: That's normal.
• 3:02
  SPEAKER_00: Nobody expects a clinician to stop in the middle of a code to type.
• 3:07
  SPEAKER_00: The question is never whether there's a gap.
• 3:09
  SPEAKER_00: The question is how big is the gap, whether there's a pattern, and whether the late entry was done the right way.
• 3:17
  SPEAKER_00: And there is a right way.
• 3:19
  SPEAKER_00: Every facility has a policy for late entries and addendum.
• 3:23
  SPEAKER_00: And so does every professional standard I've ever read.
• 3:27
  SPEAKER_00: A proper late entry is labeled as a late entry.
• 3:31
  SPEAKER_00: It carries the actual date and time it was written, it refers back to the time of the care it describes.
• 3:39
  SPEAKER_00: And it explains briefly why it's being added.
• 3:44
  SPEAKER_00: An addendum works the same way, and it adds to the original note without erasing it.
• 3:50
  SPEAKER_00: The original stays visible, the new information is clearly marked as new.
• 3:56
  SPEAKER_00: Compare that with what the audit trail showed in our pressure injury case.
• 4:01
  SPEAKER_00: No late entry labels, no explanation, a week of care entered in one sitting after the injury was already known.
• 4:12
  SPEAKER_00: Every one of those entries was dated as if it were written in real time.
• 4:18
  SPEAKER_00: That's not a timing problem anymore.
• 4:21
  SPEAKER_00: That's a credibility problem, and it doesn't stay limited to those 40 minutes.
• 4:26
  SPEAKER_00: Once a jury sees that part of a chart was written after the fact, after this injury was already known and in such a manner, they start to wonder about the rest of it.
• 4:38
  SPEAKER_00: This starts to look like a cover-up.
• 4:41
  SPEAKER_00: Now, I want to be fair here because this cuts in every direction.
• 4:45
  SPEAKER_00: Audit trails don't only hurt facilities.
• 4:48
  SPEAKER_00: Sometimes the audit trail is the thing that saves a nurse.
• 4:51
  SPEAKER_00: Say the family claims that no one checked on their father all night.
• 4:54
  SPEAKER_00: The notes are thin, but the audit trail shows the nurse opened his chart at 11, 1, 3, and 5 and scanned his medication barcode at the bedside at 2.
• 5:04
  SPEAKER_00: That's evidence of presence.
• 5:06
  SPEAKER_00: It shows someone was there and engaged, even where the narrative note is short.
• 5:11
  SPEAKER_00: So the audit trail isn't anyone's weapon, it's a record.
• 5:16
  SPEAKER_00: It tells the truth about the record and the times and the entries and who was there.
• 5:26
  SPEAKER_00: So, what does all this mean if you're reviewing a case as an expert?
• 5:30
  SPEAKER_00: First, know that the chart you receive is a printo, and a printout is a picture of the record on the day someone printed it.
• 5:40
  SPEAKER_00: It may not show edits, it may not show deleted entries, it may not show the time something was typed, it only shows the time it claims to describe.
• 5:50
  SPEAKER_00: If the timing of the care matters to your opinion, and it usually does, ask the attorney whether an audit trail has been requested.
• 6:00
  SPEAKER_00: You don't need to demand it, you just need to know whether the record you're relying on is the full story.
• 6:06
  SPEAKER_00: Second, look for the tells in the printout itself.
• 6:10
  SPEAKER_00: Entries that are word for word identical, shift after shift, repositioning documented at exact same minutes every day, notes that describe a wound as healthy on the same day another discipline describes it as deteriorating, vital signs recorded for a time the patient was documented as off the unit or even out of the facility altogether at a doctor's visit, or maybe discharged to the hospital at dialysis in radiology.
• 6:35
  SPEAKER_00: None of those prove anything in and of themselves, but each one is a reason to ask a question.
• 6:40
  SPEAKER_00: Third, and this is the one clinicians struggle with don't let the audit trail become your whole opinion.
• 6:47
  SPEAKER_00: Your job as an expert is still the standard of care.
• 6:50
  SPEAKER_00: If a late entry was made improperly, you can speak to what the documentation standard required, if that's within your expertise.
• 6:58
  SPEAKER_00: But whether someone altered a record on purpose, whether they were covering something up, that's usually not a clinical opinion.
• 7:06
  SPEAKER_00: That's a question for the jury, and often a question of fact the attorneys will fight about.
• 7:11
  SPEAKER_00: Stick to what the standard required, what the record shows, and what the timing tells you about the care.
• 7:17
  SPEAKER_00: Leave motive alone.
• 7:19
  SPEAKER_00: There's a practical warning in here, too, and it's for every clinician listening, not just the ones doing expert work.
• 7:26
  SPEAKER_00: If you ever find out a patient was harmed and you realize your documentation is incomplete, do not go back and quietly fill it in.
• 7:35
  SPEAKER_00: The system will record exactly what you did.
• 7:39
  SPEAKER_00: What would have been a documentation gap becomes something that looks like concealment.
• 7:45
  SPEAKER_00: And that is much harder to defend.
• 7:47
  SPEAKER_00: If you need to add something, follow the facility's late entry policy, label it, date it truthfully, and say why.
• 7:56
  SPEAKER_00: An honest late entry is almost always better than a perfect looking one that turns out to be new.
• 8:04
  SPEAKER_00: Let's go back to the pressure injury case one more time.
• 8:07
  SPEAKER_00: Imagine two versions of the same chart.
• 8:09
  SPEAKER_00: In the first version, the nurse's notes are sparse.
• 8:12
  SPEAKER_00: Some shifts show repositioning, some don't.
• 8:15
  SPEAKER_00: There are gaps.
• 8:16
  SPEAKER_00: It's not pretty.
• 8:17
  SPEAKER_00: But every entry was made during the shift it describes.
• 8:20
  SPEAKER_00: In the second version, the chart is complete and polished, and the audit trail shows it was built after the wound was found.
• 8:27
  SPEAKER_00: First chart has a documentation problem.
• 8:29
  SPEAKER_00: The second chart has a trust problem.
• 8:32
  SPEAKER_00: An expert can work with the first one.
• 8:34
  SPEAKER_00: You can say what was documented, what wasn't, and what this tells you about the care.
• 8:39
  SPEAKER_00: With the second one, everything the chart says is now in question, including the parts that might have been true.
• 8:46
  SPEAKER_00: So here's the takeaway.
• 8:48
  SPEAKER_00: The chart remembers every entry has two times.
• 8:52
  SPEAKER_00: The time it describes and the time it was written.
• 8:55
  SPEAKER_00: And in litigation, both of them matter.
• 8:58
  SPEAKER_00: When timing is part of your opinion, ask whether the audit trail has been produced.
• 9:05
  SPEAKER_00: Read the printout for patterns, not just for content.
• 9:08
  SPEAKER_00: And keep your opinion anchored to the standard of care, not to guesses about motive.
• 9:15
  SPEAKER_00: This is educational information, not legal advice.
• 9:18
  SPEAKER_00: What an audit trail shows depends on the system and the facility, and the rules on requesting it vary by jurisdiction.
• 9:24
  SPEAKER_00: The attorney on the case decides how it gets used.
• 9:31
  SPEAKER_00: If it was useful, follow the show so the next one finds you.
• 9:35
  SPEAKER_00: And if you're a clinician who wants to do this work properly, start with the Expert Report Starter Kit at National Expert Academy.com.
• 9:42
  SPEAKER_00: I'm Tracy Librettor.
• 9:44
  SPEAKER_00: I'll see you on the next episode.