By law, every nursing homes using computerized medical records must have a system that can generate a log or audit trail showing not only every electronic entry, but every access of the electronic record.  The audit trail prevents the alteration of the records without leaving a telltale trail behind.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the establishment of national standards for
electronic health care transactions. Health care providers were to implement security measures to ensure that electronically
transmitted and electronically protected health information “is not improperly modified without detection until disposed of.”
HIPAA also mandated that health care facilities retain the required documentation (including audit trail data) “for six years from the date of its creation.”

More recently, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) was designed to “build
trust in health information exchange. HITECH, in addition to protecting medical information and personal data, also provides for an increased transparency to patients, who now are supposed to be granted access to their own electronic records within 30 days of the request.

Additionally, patients should be permitted access through a portal, so they can see the records in the same format that the healthcare providers see when they are making or accessing the patients’ records.

Why is this important?  Here is an example why.

Diana L. Stephens, a nurse at Golden Hill Nursing Home, is facing charges for allegedly stealing oxycodone and codeine while employed.  She had worked at the home from September 2015 through January, according to an affidavit.

Stephens is accused of diverting the painkillers by signing out the drugs on the controlled substance log, but the amount showed discrepancies on the patients’ electronic medication administration record, according to the affidavit that the agent filed in court.  The discrepancies showed that the patients were getting a lot fewer of the dosages units than Stephens had signed out.

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