A Case of an Edited Medical Record
The Medical Record Audit Trail
After OHSU Hillsboro Medical Center learned of Tiffany’s sexual assault allegation, Tiffany’s medical record was edited to conceal the fact that she was alone with Dr. Hildebrant during the time of her alleged sexual assault. Tiffany’s medical record was also edited to conceal the anal pain Tiffany reported.Tiffany’s modified medical record was provided by OHSU Hillsboro Medical Center to Hillsboro Police Department, and placed into evidence for the sexual assault case at Hillsboro Police Department.
OHSU Hillsboro Medical Center uses the Epic electronic health record (EHR) system. The Epic EHR system contains an audit trail that tracks all changes made to each patient’s records. The Health Insurance Portability and Accountability Act (HIPAA) grants individuals the right to access their protected health information (PHI), which includes electronic health records. As explained by a court order for a lawsuit in Illinois, audit trails for electronic health records are considered part of the protected health information because they document who accessed, modified, or deleted information related to a patient's health. Thus, HIPAA grants patients the right to access their electronic medical record audit trail data.
When Tiffany realized that her medical record had been modified, she requested access to her OHSU Hillsboro Medical Center electronic medical record audit trail and scheduled an appointment with the hospital’s records department for June 25, 2025 to view her audit trail on a computer at the hospital. Although Tiffany had not yet filed a lawsuit against the hospital, on June 19, 2025, the hospital sent Tiffany an email stating, “For your request regarding your complete audit trail, that is not a part of the designated record set, and that request would need to go through our attorney. Therefore, we will cancel the meeting we have scheduled for next Wednesday, the 25th.”
Later, Tiffany filed a lawsuit against OHSU Hillsboro Medical Center and requested access to her audit trail as a “request for production” in the lawsuit. The hospital still refuses to provide Tiffany with her complete audit trail record. In a response to Tiffany’s request for production, the hospital stated that they will not allow Tiffany to inspect her audit trail at the hospital, but will provide a document that is a “redacted” version of Tiffany’s audit trail record, because allegedly parts of Tiffany’s medical record contain “privileged, confidential, and unrelated” information.
The Medical Record Edits
After her surgery, Tiffany was left alone with Dr. Hildebrant at approximately 18:28 hours, sodomized, and then brought to nurse Dawn Marie at approximately 19:35 hours. Originally, Tiffany’s medical record stated that she was transferred to female nurse Dawn Marie at about approximately 19:35 hours. However, Tiffany’s medical record was modified to state that Tiffany was transferred to Dawn Marie at 18:35 hours.
Tiffany’s medical record was also modified to falsify that Tiffany first reported minimal pain in her anus and that she reported greater pain in her anus over time.
The Technical, Specific Details:
OHSU Hillsboro Medical Center uses the Epic electronic health record (EHR) system. The Epic EHR system contains “flowsheets.” Flowsheets are organized like spreadsheets and each column in a flowsheet corresponds to a different time period. The flowsheets allow medical practitioners to record and track clinical data, such as vital signs, over time.
It is unknown whether Tiffany’s medical record was edited in the Epic electronic health record (EHR) system, or if a PDF of Tiffany’s medical record was edited by OHSU Hillsboro Medical Center. It is very easy to edit PDFs in Adobe Acrobat.
After OHSU Hillsboro Medical Center learned of Tiffany’s sexual assault allegation, flowsheet columns for 2 time periods (a time period starting at 18:34 hours, and a time period starting at 18:35 hours) were added to the flowsheets in her medical record. The columns for these 2 time periods contain data anomalies indicative of medical record tampering:
The columns “07/21/23 1834” and “07/21/23 1835” are the only columns in Tiffany’s flowsheets that contain timestamps that don’t belong in the columns the timestamps were added to. (In an Epic flowsheet, the title of a column indicates the start time for the column. Data should not be entered in a particular column if the data occurred after the start time of a subsequent column.)
The “07/21/23 1834” columns were created after-the-fact by copying another column. For this reason, the “07/21/23 1834” columns contain records that are exact copies of records from different columns. For example, in the “Level of Consciousness" row of the “Adult PCS Perioperative” flowsheet, both the “07/21/23 1834” column (a falsified column) and the “07/21/23 1945” column (a real column) state “alert -DM at 07/21/23 2107.”
The “07/21/23 1834” column in the “Peri-Op VS” flowsheet falsified that nurse Dawn Marie selected a numeric pain scale at 18:58 hours to enter Tiffany’s pain rating. The same column also falsified that Tiffany rated her pain level as a mere 3 out of 10 at 21:04 hours. A timestamp for 21:04 hours belongs in a different column. The “07/21/23 1945” column of the same flowsheet indicates that at 21:04 hours Dawn Marie recorded a pain level of 6 out of 10 for Tiffany. Obviously, the note that at 21:04 hours Tiffany reported a pain level of 3 out of 10, and the note that at 21:04 hours Tiffany reported a pain level of 6 out of 10, are contradictory.
In the “Transfer of Care” section of the “Peri-Op VS” flowsheet, the “07/21/23 1834” column falsified that at 18:35 hours, Tiffany was transferred from nurse Kaitlin Ray to nurse Dawn Marie.
On August 8, 2023, Tiffany requested her complete medical record for July 21, 2023. In response, OHSU Hillsboro Medical Center provided Tiffany an incomplete version of her medical record without the “flowsheets.”
“After Dr. Hildebrant raped me, he rendered me unconscious with a gas anesthetic. Then I came to in the custody of a female nurse. That evening, I didn’t tell staff at the hospital that I had been raped because I was groggy from the anesthesia and I couldn’t run, and I didn’t know how to remove the IV cannula in my arm. I felt vulnerable and was scared Dr. Hildebrant would come to the room and hurt me if I told someone. I did tell a female nurse that I was experiencing pain in my anus, but I didn’t admit the pain was an 8 out of 10. I worried that might raise an alarm and Dr. Hildebrant might realize that I knew he assaulted me.”
The Crime of Hindering Prosecution
In Oregon, hindering prosecution is a Class C felony, carrying penalties of up to 5 years in prison and/or fines up to $125,000.
In Oregon, a person who intends to hinder the apprehension, prosecution, or punishment of a person who has committed rape, commits the crime of hindering prosecution if the person does one of the following things:
Provides or aids in providing a person who has committed rape with a means of avoiding discovery or apprehension
Prevents or obstructs, by means of force, intimidation or deception, anyone from performing an act which might aid in the discovery or apprehension of a person who has committed rape
Suppresses by any act of concealment, alteration or destruction physical evidence which might aid in the discovery or apprehension of such person
The Crime of Tampering with Evidence
In Oregon, tampering with physical evidence is a Class A misdemeanor punishable by up to 364 days in jail, a fine of up to $6,250, or both.
In Oregon, a person commits the crime of tampering with physical evidence if, with intent that it be used, introduced, or unavailable in an official proceeding, the person does one of the following things:
Destroys, mutilates, alters, conceals or removes physical evidence impairing its availability or state of being true or real
Knowingly makes, produces or offers any false physical evidence
Prevents the production of physical evidence by an act of force, intimidation or deception against any person