Electronic health record systems automatically log user activity: which user viewed a record, what was entered, when entries were made or amended, and whether alerts were displayed or overridden.
The log frequently contains information not visible in the printed chart, including the actual time of entry as opposed to the time documented.
Alternative Names:
Audit Log (EHR), Metadata Audit Trail
Why it Matters?
Audit trails have become standard discovery in malpractice and long-term care cases because they answer questions the chart cannot. They reveal whether a critical result was actually opened, whether an entry was made hours after the event it describes, and whether a clinical decision support alert was dismissed. Preservation matters, since some systems purge logs on defined schedules, and production disputes over format and scope are routine.
Frequently Confused with
Related terms
Frequently asked questions
What does an EHR audit trail reveal?
Is the audit trail discoverable?
