The audit trail captures user identity, access time, actions taken, entries created or amended, and in many systems whether clinical alerts were displayed and how they were resolved.
It is generated automatically and cannot ordinarily be edited by clinical users.
Alternative Names:
EHR Audit Log, Access Log (EHR)
Why it Matters?
Audit trails answer questions the chart cannot, and they cut both ways. They can show a critical lab result was never opened, or that documentation was entered retrospectively. They can also demonstrate that a nurse checked on a patient exactly as charted, which defeats a neglect allegation. Retention periods vary by system, so preservation demands should issue early rather than after the pleadings close.
Frequently Confused with
Related terms
Frequently asked questions
What does an audit trail reveal that the chart does not?
How long are audit trails retained?
