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Audit Trail Metadata Is Discoverable

In this medical malpractice case, a Hampton Circuit Court orders defendant hospital to provide its Policies and Procedures Manual, as well as the requested Audit Trail, including metadata.

Many Virginia circuit courts have ruled on this issue within the last 30 years. One most prolific writer has been Justice Donald W. Lemons of the Virginia Supreme Court when he sat as a circuit court judge. The clear direction of those rulings is an inexorable march to more disclosure.

Following these rulings and those of many other circuits, I rule that defendant’s Policies and Procedures Manual is discoverable. This document may lead to discoverable evidence. While a Policies and Procedures Manual does not set the applicable standard of care, it does reveal an environment in which the standard of care may be considered. Whether or not the Manual is admissible is not addressed here.

There is no dispute, and it is well settled, that medicine has long past evolved from that time when a “patient’s chart” was a clipboard hung on the foot of the bed. The ability to record and store vast quantities of information about a patient grows rapidly. The General Assembly is challenged each year with revision of Va. Code § 8.01-413 in updating the law as record keeping advances even faster. That difficulty does not diminish the intent of the law to instruct that a patient is entitled to review his or her entire “medical record.” The Audit Trail sought by plaintiff in this matter is discoverable. This includes Metadata.

Eason, Adm’x v. Sentara CarePlex Hospital (Hutton) No. CL 12-470, May 29, 2014; Hampton Cir. Ct.; Avery T. Waterman Jr. for plaintiff; Dorinda P. Burton for defendant. VLW 014-8-056, 2 pp.

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