What is an audit trail in health information management?

An audit trail in health information management refers to a systematic record that traces the sequence of events related to the access and modifications made to health data. This documentation is crucial for ensuring data integrity, security, and accountability within electronic health records (EHRs). An audit trail enables health information managers and auditors to monitor who accessed specific information, what changes were made, and when these actions occurred. It plays a vital role in regulatory compliance, helps identify potential breaches of security, and ensures that the organization adheres to policies regarding patient confidentiality and data handling.

In the realm of health information management, audit trails are essential for maintaining trust in healthcare systems, as they provide a transparent view of data usage and alterations, which can be critical when resolving disputes or investigating unauthorized access.