Get the real information about the medical records by requesting the records in Native File Format including the Audit Trail of the record to see if there has been any manipulation of the data.

1. {
Metadata in
Medical Records
Getting medical records in their native file
format will provide the metadata showing if the
records have been altered.
Presented by: Geo Bellas
www.bellas-wachowski.com

2. The Verdict – Dealing
with Fudged Evidence
Forged Hospital Record
How do we deal with this
problem in the 21st Century
when all records are stored
in electronic format?

3. Get the Medical Records
• A patient is entitled to get their medical
information in electronic format upon request,
and that should include the metadata
• 42 U.S.C. §§300jj et seq; §§17901 et seq; 45
CFR §164.524
• In the Request for Production ask for the audit
trail of the record
• This is more important than the record itself
• Do not take no for an answer

4. What to ask for?
• Request Audit Trail Information
• Request Loggin Information
• Request the Data Dictionary
• Do not accept a .pdf of the
information – It can be modified
when put on paper.

5. Getting Hospital Records
in Native File Format
• Send request to the hospital Legal Counsel or Chief
Information Officer, not the Records Custodian
• Detail the information you are seeking:
• ie, need to know when medical and nursing licensed
personnel documented on the chart and the time the
changes were made - so you want the information
surrounding the file that shows the changing of the file

6. Getting Hospital Records
(The hard part)
• No standards in the industry
• All medical providers have different databases and these buzz
terms with get them to sit up, notice and balk...but most likely
won't produce anything. For example, audit trail information may
not exist.
• The data dictionary will be useless without the key to
corresponding tables. The facilities might not even have canned
reports that they can spit out.
• You could request a “Coma Delimited File” that would contain the
information you are seeking, but in a spreadsheet type format that
neither you nor possibly anyone else could understand.
• Bottom line . . . Very expensive and hard to get.

7. Conclusion
• Practicing law in the 21st Century
presents new challenges for trial
lawyers.
• Technology controls every aspect of
business and we must adapt to the
changing paradigms.
• Join the 21st Century and adapt to the
changes:
• www.attorneyscreativeroundtable.com