Sample findings

What a findings report actually looks like

A redacted sample audit-trail findings report is available on request. It shows how raw EMR metadata becomes organized, defensible evidence — without reproducing any real patient or case material here.

What the report contains

Every engagement produces a structured findings report built from the record's audit trail and metadata. The redacted sample walks through all six sections:

  • 01

    EMR authenticity & completeness report

    Independent verification of the record produced in discovery — version, export integrity, and whether what you received is the complete electronic record.

  • 02

    Audit-trail & metadata findings

    Late entries, post-event edits, signs of backdating, deletions, and the access log — the medical-record metadata that shows how the chart was assembled.

  • 03

    Annotated chronology

    An event timeline synced to exhibits and pleadings, with annotations mapped to the underlying audit-trail evidence.

  • 04

    Standards-of-care cross-references

    Variances from documented standards, framed in terms a trier of fact can follow — not a clinical opinion dressed up as data.

  • 05

    Provider background summary

    Licenses, board certifications, disciplinary actions, and publicly available history relevant to the record at issue.

  • 06

    Declaration / affidavit template

    Filing-ready language tailored to the jurisdiction, ready for your review and execution.

How findings are presented

Audit-trail evidence only persuades if a non-technical reader can follow it. Findings are presented as a clear before/after of the record — the entry as produced versus what the metadata shows about when and how it was created:

audit_trailEpic· Patient #—— · illustrative
Illustrative Epic audit-trail excerpt showing a late, back-dated entry.
Timestamp (UTC)UserActionDetail
2024-03-11 22:47:03RN J. DoeCREATEProgress note created — status: draft
2024-03-11 23:02:10RN J. DoeVIEWVitals flowsheet opened
2024-03-12 08:55:41Dr. A. RoeVIEWProgress note opened
2024-03-12 09:14:55RN J. DoeEDITFlagged: Progress note edited — entered late, back-dated to 03-11
2024-03-12 09:15:10RN J. DoeSIGNProgress note signed
FindingThe printed chart shows a single note dated the night of 03-11. The audit trail shows it was actually written — and back-dated — the next morning, roughly 10 hours after the event it describes.
The sample is redacted and illustrative. It demonstrates format and method — see audit-trail analysis for what the underlying review covers.

This page is educational information, not legal advice. EMR Check provides consulting and analysis services, not legal representation.

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