DATA ABOUT DATA: What You Should Know

You can learn so much from the metadata in the electronic health record (EHR).  Metadata is data, about data.

Example: data entered, patterns of missing data, when data was entered, who entered it, who viewed it, how long it was viewed for, and whether it was modified.

Metadata can identify incidences of errors, as well as patterns of patient care delivery (i.e., recurrent late entries)

Metadata is discoverable per the Federal Rules of Civil Procedures. This means that attorneys can acquire access to EHR information, including the metadata, through the discovery process. Metadata is typically  obtained by a computer-generated record of audit trails showing user access and actions.  

Providers Can Minimize Risk by Effectively Documenting: During the litigation process, metadata can play an integral role in determining the credibility of evidence, including healthcare provider’s testimony, and documentation.

  • Avoid documentation gaps
  • Don’t copy and paste text from one patient’s EHR to another
  • Use templates and checklists cautiously
  • Do not share your password
  • Make any changes to the record as soon as possible, per organizational policy
  • Know that what you view is recorded
  • Document referrals and notifications of other nurses about changes in a patient’s condition

Metadata analysis can support — or not support — a lawsuit. Frequent errors, and errors of omission can negatively impact a healthcare providers credibility in court.  Contrary, metadata that demonstrates  complete, and accurate documentation can help exonerate healthcare providers by bolstering their credibility, and providing evidence that adherence to organizational policies, and procedures, as well as  standards of practice were followed.


  • AHIMA. E-discover litigation and regulatory investigation response planning: Crucial components of your organization’s information and data governance processes. n.d.
  • Barrett M, DeAngelo TR, DeAngelo JG. E-discovery: Metadata analysis in medical malpractice litigation. The Legal Intelligencer. 2020. Commentary.
  • Conn J. Making IT legal-size; As electronic health-record systems become more complex, so do the issues involving the legal status of those records. Modern Healthcare. 2008;38(20),
  • Gardner E. The weight of the I.T. evidence; why EHRs won’t reduce your malpractice premiums. Health Data Management. 2013;21(10).
  • Hansen MD, Pratt TJ. Follow the audit trial: The impact of metadata in litigation. Defense Counsel J. 2017;84(3).
  • NSO, 2024. What nurses need to know about metadata, documentation, and legal liability.
  • Shwayder JM. Electronic records and metadata: Old and new liability risks: Metadata from an EHR form an audit trail of activity, which can make or break a malpractice case. Cont OB/GYN. 2018;63(9).

P.S. COMMENT & SHARE: What has been your experience utilizing metadata to support your medical legal cases?


In this blog, I’ll be reviewing the incidence of cardiovascular disease (CVD) in pregnancy, and postpartum.  Additionally, I’ll present a case presentation in an effort for the reader to reflect on the learned knowledge from the blog post in the context of the presented case. I’ll also address the challenges associated with diagnosing CVD in pregnancy, and postpartum, while highlighting the signs, and symptoms as well as risk factors for CVD. In closing, I’ll conclude with key takeaways.

Incidence: Cardiovascular disease (CVD) is one of the leading causes of maternal mortality in the United States accounting for >33% of all pregnancy-related deaths in the U.S.  One of every three intensive care admissions in pregnancy, and the postpartum period are related to CVD. CVD is under-recognized in pregnant, and postpartum women with rates higher among African-American women.

It’s estimated that 25% of deaths caused by cardiovascular disease in pregnancy or during the postpartum period may have been prevented if CVD had been diagnosed earlier.  Only a small fraction of women who die from CVD have a known diagnosis of CVD prior to death.  The majority of women who die from CVD present with symptoms either during pregnancy or after childbirth


Diagnostic Challenges and Signs/Symptoms: Signs, and symptoms of normal pregnancy, and postpartum mirror CVD making it difficult to diagnose.  This is due to the normal physiological changes that occur in pregnancy, and the postpartum period.  However, a diagnosis of CVD should be suspected when symptoms are severe (see red flags below) with vital sign abnormalities, and underlying risk factors.  Having an increased awareness of the prevalence of CVD, and a high index of suspicion, along with preconception counseling, and referral to a higher level of care can prevent adverse maternal outcomes. 


Risk Factors: Risk factors for the development of CVD in pregnancy, and postpartum include polycystic ovary syndrome, infertility, adverse pregnancy outcomes such as hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction. 

Key Takeaways:

  • Symptoms related to the normal physiological changes of pregnancy should improve in the postpartum period.
  • The highest risk period for CVD worsening is between 24-28 weeks of pregnancy or postpartum.
  • Emergency Room visits for dyspnea (shortness of breath) should heighten suspicion level for CVD.
  • Postpartum dyspnea or a new onset cough should heighten suspicion for CVD.
  • New onset asthma is rare in adults.
  • Bilateral crackles are likely related to congestive heart failure (CHF).
  • Bilateral infiltrates on chest x-ray may be due to heart failure rather than pneumonia.
  • Hypertension and diabetes in pregnancy increases the risk of CVD.
  • Healthy lifestyle changes can reduce future CVD risk by 4-13%.


ACOG, 2019. Pregnancy and heart disease.

AHA, 2020. Cardiac arrest in pregnancy in-hospital ACLS algorithm.

AWHONN, 2023. Obstetric patient safety ob emergencies workshop, 3rd ed.

CMQCC, 2017. Cardiovascular disease in pregnancy and postpartum toolkit.

P.S. COMMENT AND SHARE: What is your experience with cardiovascular disease in pregnancy or in the postpartum period?  Have you been involved in an adverse outcome as a result of a CVD diagnosis, or failed diagnosis?