This case study deals with an outpatient surgery that resulted in serious complications. The patient experienced surgically induced hypoxia, resulting in quadriplegia. Allegedly, the physician responsible for the procedure copied and pasted the operative notes from another patient's records, making retroactive alterations post-surgery.
An expert in electronic medical record (EMR) audit trails was sought to review these electronic records, specifically using eClinicalWorks® software, to determine if any post-procedure alterations were made to the operative notes.
Questions to the Electronic Medical Records expert and their responses
Can you describe your professional background in electronic medical record auditing, particularly with eClinicalWorks® software?
I have been deeply involved in various aspects of EMR development and implementation for almost 20 years. My current role is as an EMR application analyst within a large national healthcare system. My expertise includes reviewing cases involving non-contemporaneous editing of physician documentation, several of which utilized the eClinicalWorks® medical record system.
What is needed to determine if any edits were made to the patient's operative notes after the procedure?
To determine if any edits were made to the patient's operative notes post-procedure, a comprehensive review of the medical records is essential. I would need a searchable version of the patient's medical record and a complete audit report in electronic spreadsheet format. This report should include activity related to both the patient and the physician in question, from their first encounter until the production of the evaluated medical records.
Have you ever reviewed a similar case? If yes, please elaborate.
Indeed, many cases I've reviewed involved situations similar to this one where modifications, additions, or deletions to clinical documentation were made well after a critical event occurred. In some instances, clinical notes were altered numerous times, non-contemporaneous documentation was added, orders were altered, and assessments were modified.
About the expert
This expert has over two decades of experience in electronic medical records, with a background in nursing and psychology. They hold multiple certifications including healthcare technology professional, HIPAA security professional, HIT security manager, and are a licensed registered nurse. Their extensive career includes roles as a senior consultant at major healthcare solutions companies, clinical informaticist, systems consultant, EHR application specialist. They currently serve as an EHR application coordinator for a Michigan-based healthcare system, while also consulting for an independent electronic medical record systems' consultancy.