Medical Record Audit Trail Log
Document every access or modification to patient medical records for compliance and accountability.
Full Name of Staff Member
*
First Name
Last Name
Role/Position
*
Please Select
Physician
Nurse
Medical Records Staff
Administrator
IT Staff
Other
Patient Name
*
First Name
Last Name
Patient ID (if applicable, last 4 digits only)
Date and Time of Access/Modification
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Action Performed
*
Viewed Record
Edited Record
Deleted Record
Printed Record
Shared/Exported Record
Other
Reason for Access/Modification
*
System or Location of Access
*
Please Select
Electronic Health Record System
Paper File Room
Remote Access
Other
Was the access authorized?
*
Yes
No
Additional Comments or Notes
Signature of Staff Member
*
Submit Audit Log
Submit Audit Log
Should be Empty: