25 Trial Lawyer • Summer 2023 #1. The words “necrotizing fasciitis” appeared four times in her chart notes and orders, which were immediately available in the hospital EMR system. The hospitalist ordered the orthopedic surgeon consult because she knew visual examination of the fascia was necessary to diagnose necrotizing fasciitis, and she expected the orthopedic surgeon to take Jean to exploratory surgery that night. The surgeon According to the medical records, the consulting orthopedic surgeon arrived just after 5 p.m. The orthopedic surgeon was not an employee of the hospital. In his consult note, it appeared he carefully documented a thorough exam for necrotizing fasciitis. He charted that he reviewed the notes of the emergency room doctor and the hospitalist. He charted that he reviewed the CT scan and found no trapped air under the skin. He charted that he examined Jean’s thumb and arm for symptoms of necrotizing fasciitis and documented their presence or absence: no purulent drainage, some swelling, slight induration, no crepitus, minimal blisters, no fever, skin cool. Under the “plan” section of the record, he wrote “serial exams,” indicating he understood the risk the infection posed and that it should be monitored regularly. (However, he also covered her hand and arm in gauze bandages and placed it in a splint from the thumb to the elbow, making serial exams almost impossible.) With her hand and arm covered in bandages, no one removed the bandages and examined her arm until 8 a.m. the next day when the hospitalist returned to check on her patient. She was shocked to see that the orthopedic surgeon had not taken Jean to exploratory surgery. The hospitalist removed the splint and unwrapped the gauze to find Jean’s forearm swollen and hot, and her skin blistered, split and oozing. Later that afternoon, surgeons amputated Jean's arm and removed tissue from her chest wall, but the infection had progressed too far. Jean died on Tuesday, four days after she smashed her thumb. The audit log After studying the medical records the hospital provided in discovery, we requested the audit log to get a more detailed time line. In this particular case, the hospital was unusually cooperative and produced a variety of audit logs for Jean. The audit log is a complete record of entries regarding patient care information automatically collected and stored by electronic health record software. (See ASTM E2147-18, standard specification for audit and disclosure logs for use in health information systems.) There are various brands of electronic health record software, including Epic and MediTech. The audit log shows the sequence of events related to the use of and access to an individual patient's electronic medical See Audit Trails p 26 See Audit Trail p 26
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