EMR Data Interpretation – Finding the Story in the Data
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EMR Data Interpretation – Finding the Story in the Data
The Evidence Hiding in Plain Sight
EMR systems store vast amounts of data, but the real challenge is making sense of it. Our experts help legal teams and healthcare organizations interpret critical metadata, including:
- Modified and deleted notes
- User access logs
- System alerts that may indicate negligence
Electronic Medical Records (EMRs) contain far more than just clinical notes—hidden within them is a digital trail of every action taken by healthcare providers. The key to building a strong case is understanding the metadata that reveals when, how, and why changes were made. Our experts help legal teams and healthcare organizations interpret critical EMR data, including:
Modified and Deleted Documentation
Clinical documentation in an EMR can be altered after an adverse event, sometimes in an attempt to correct documentation—or to obscure liability. Audit trails can reveal when a provider’s note or nurse’s assessment was originally written, whether it was edited, and if key details were changed or removed. For example, in a birth injury case, an initial obstetrician note might reflect a delayed C-section decision, but a later modification could downplay the urgency, creating inconsistencies that impact the case. These modifications are often not revealed in the legal medical record production that tells a more idealistic clinical story without critical metadata about the revisions.
User Access Logs
Knowing who accessed a patient’s record and when can confirm or contradict testimony. If a provider claims they reviewed a critical test result before making a treatment decision, but the audit trail shows they never accessed it, this discrepancy can be pivotal in proving negligence. Similarly, repeated access to a patient’s record by unauthorized users, clinicians not connected with the care of the patient, risk management or legal teams before an official investigation may indicate awareness of potential liability.
System Alerts May Indicate Negligence
EMR systems can be configured to generate automated warnings known as clinical decision support (CDS) alerts for potential drug interactions, abnormal lab values, and other clinical risks. If a physician ignored or overrode an alert without taking appropriate action, it could demonstrate a failure to provide standard care. Poorly designed and implemented CDS alerts have inundated EMR users leading with repetitive alerts throughout their practice experience. In a medication error case, audit logs might show that an alert for a high-risk drug interaction was reflexively dismissed in seconds—suggesting the provider did not fully review the warning before proceeding.
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