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Falsification of Documentation & Provider Behaviors in Two EMR Systems

Filed Under: , Case Studies
June 27, 2022 by dev_team


Morgantown, WV

EMR Systems:

Epic (Ambulatory & Inpatient) Harris Healthcare (CareTracker)


This medical malpractice case involving a 58-year-old female with a history of worsening back pain. She was being treated over the course of 2 years by a Physical Medicine and Rehabilitation (PM&R) physician, also known as a physiatrist, among others at an academic medical center. Throughout the woman’s clinical course, there were several different hospital visits with the PM&R physician that are documented using the EPIC electronic medical record system; however, the PM&R physician additionally maintained an active private practice and documented several visits to this office using the Harris CareTracker Software. As such, the audit trail now contains notations from EPIC and the Harris Caretracker Software. In reviewing medical records from both systems, there appeared to be a significant amount of copied assessment information between visits as well as instances of erroneous or inconsistent entries in the defendant’s notes.


In the private office setting, the defense team struggled to supply additional requested documents and claimed to be working with the Harris Healthcare EMR company to produce materials for the requests. Our team obtained educational materials and resubmitted requests with specific, step-by-step instructions for the defendant’s office manager to follow in order to produce more substantive information pertaining to the case. This included novel entries into the system, timestamps for actions that occurred in relation to the plaintiff’s office visits as well as additional audit trail details not originally included in the original audit trail. Additional requests, supported by instructions outlined in the EMR’s user documentation, produced additional metadata around the composition of each note, including what information was copied from a prior note and what information was entered manually into the new note. With timestamp and user attribution information for all components of the finalized note, we were able to order and reconstruct the events of each visit noting when the provider was in the room with the patient, and composing notes some time after the encounter with a significant portion copied from a prior visit including specific details tied to each individual entry contained.

In the health system setting, the focused on the provider’s use of dictation systems and the process of transcribing the recorded encounters into notes in the Epic System. Note versioning annotation in the legal medical records provided clues that more information was preserved in Epic than was provided during discovery. Some of this versioning was attributed to creating the record for which the dictated note content would be merged at a later date, but other versioning metadata revealed co-signature of assessment generated by other providers. Additionally, Epic’s extensive audit trail responses were closely investigated and compared against the legal medical record; additional requests for missing information were made as indicated by line entries in the audit trail without corresponding entries found in


By extracting additional EMR content from each system beyond what was originally provided, we were able to decipher more granular details from both EMR systems to compare how the defendants notes were conceived and were modified throughout the course of the patient relationship.


Discovery Request Support; Medical Record Review; Lawyer Education; Audit Trail Analysis; Digital Timeline Reconstruction

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