Electronic Audit Trail

Last updated: September 12, 2011

What Does Electronic Audit Trail Mean?

An electronic audit trail in the context of electronic medical records (EMR) is used for the following reasons:

  • Security purposes to gauge who has logged into patient records.
  • Medical billing purposes.
  • Data gathering for public health reporting and medical research.

EMRs should be protected and secure due to their online status. Not only is it imperative to protect EMRs from unauthorized outside access but data trails are necessary in order to make sure that they are accessed only on a need-to-know basis in-house. Laws such as the Health Insurance and Accountability Act (HIPAA) demand that only authorized users accsess medial records.


Techopedia Explains Electronic Audit Trail

Laws are firmly in place that guide healthcare administrators and staff as to ethics surrounding medical records and patient confidentiality. Failure to do so can result in hefty penalties as well as jail time. Electronic audit trails for EMR access points should be designed to ensure confidentiality compliance and authentication. Not only are related HIPAA laws extremely important, but health care organizations are sometimes required by state and federal public health agencies to gather data diagnoses and disease outbreaks. The time allotted for this is usually minimal and so EMR systems need to be designed with this in mind.

Another use for data audit trails is to track medical billing records. Medical bills were undoubtedly electronic well before medical records. But they have become so automated that when electronic progress notes, surgical notes or discharge treatment notes enter the electronic system, the code for the diagnosis or procedure is automatically sent to the billing department. Electronic audit trails can also be utilized for medical research purposes to collect data and to readily reconcile trial medication adverse reactions with an at-a-glance feature such as an audit trail.


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