Sunday, September 2, 2018

EHR evidentiary mayhem

A short post.

I am encountering, in my legal work, electronic medical records
systems that either allow ex post facto note alterations by clinicians -
for example, after a catastrophe - and/or alteration of the apparent
date/time a note was entered. The alterations (e.g., a version history) or fake times don't
appear on the printed records, and usually are not in the audit trails as well.

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