In this medical malpractice case arising from the death of a twin baby in utero about 30 minutes before delivery, the plaintiffs sought production of the hospital’s “audit trail” showing the timing of all entries in the patient’s electronic record by the nurse who was assigned to monitor the labor, which was induced with Pitocin due to intrauterine growth restriction of the twin fetuses. The nurse claimed that she vigilantly monitored the patient’s fetal heart monitor throughout her eight-hour shift. The mother, on the other hand, claimed that she had only seen the nurse once or twice during the entire eight hours. The audit trail showed that most of the entries made by the nurse in the electronic record were entered into the system at the end of the nurse’s shift. She testified that she had made handwritten notes contemporaneously throughout the shift and then transcribed those entries into the electronic record and destroyed the handwritten notes. The plaintiffs then sought further discovery of audit trails for any other patients monitored by this same nurse during the relevant time. In this request for documents, motion and order by the court, the plaintiffs won discovery of these other audit trail documents, with identifying information for the other patients redacted to protect privacy.
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