Audit trail
Also called Access log, Audit log
An audit trail records who viewed, added, changed, shared or exported a record and when, so access can be reviewed and incidents investigated.
Why it matters in a workup
Patients can ask who accessed their record, and an organization needs to answer. An audit trail is how it does.
Ask any tool what it records, how long it keeps the log and whether you can export it.
Put it into practice
- Ask what events are logged
- Ask how long logs are kept
- Check you can export them
Frequently asked questions
Is an audit trail the same as version history?
Not quite. Version history shows how a document changed. An audit trail also records who viewed and shared it.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- Data processing agreementA data processing agreement is the contract under which a vendor processes personal data for your organization. In US healthcare the equivalent is a BAA.
- De-identificationDe-identification removes or alters details that identify a patient, such as name, date of birth and record numbers. It lowers risk but rarely removes it.