Hunter Hillin and Robin Loeb recently obtained an Order from the State Court of Dekalb County granting them the right to an electronic inspection of a client’s medical record. The electronic inspection will allow them to see what changes were made in the client’s medical record, who made them, when, and from what work-station. Most importantly, it will reveal the text of the original entry, together with the change. An examination such as this is helpful in determining whether practitioners at the hospital “sanitized” the record after the very unfortunate events at the hospital resulted in brain damage suffered by an infant at birth.
Until relatively recently, hospitals maintained their medical records in a paper format. If a change was to be made to a handwritten entry in those records, it needed to be stricken through, and initialed by the person making the change. Accordingly, all changes made the record were very obvious. When lawyers got copies of hospital records, sometimes it was unclear if there had been some improper “whiting out” made on the original, and a demand could be made to inspect the original record at the hospital facilities.
But the advent of electronic medical records changed all of that. Now, when an electronic medical record is produced, it is impossible to determine from the document itself if it has been changed. Audit trails and audit logs can be demanded, and they generally reveal if changes have been made. Nevertheless, it is only an inspection of the electronic medical record itself that truly provides all of the data needed to determine if -- and what -- changes have been made. Seeking an order for that inspection is a new and novel approach to the age-old dilemma of figuring out what tinkering has been done with the record. The Order obtained from the Dekalb Court is an important development and reinforces the right that all patients have – protected under federal law – to full access to everything in their own medical record.