Glossary, records and interoperability
What is a clinical audit trail?
A clinical audit trail is the time-stamped log of who viewed, created, changed or signed each part of a patient record. It lets a clinic show exactly what happened to a record, by whom and when, long after the event.
Updated . Defined by the wai team for clinics, groups and health systems.
Also called audit log or access log.
Why Clinical audit trail matters to a clinic
Regulators and laws expect it. In the United States the HIPAA Security Rule requires mechanisms that record and examine activity in systems holding health information,1 and in England CQC regulation 17 asks providers to keep accurate, complete and contemporaneous records.2
The audit trail is also where an incident review starts. When a result is missed or a letter goes to the wrong person, the log answers the first three questions, who saw it, who changed it and when, in minutes rather than days.
Questions
How long should an audit trail be kept?
As long as the record it describes, at least. Retention periods are set by each country's rules for medical records.
Can staff edit the audit trail?
They should not be able to. In wai staff work under named accounts with role-based access, and their actions are written to the log rather than to anything they can change. See security.
Sources
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