Medical Record Review: What Attorneys Should Know

Medical records are not written for litigation. They are written for other clinicians, in shorthand, under time pressure, and often across incompatible systems. A well-organized chart from a large academic center may run several hundred pages of duplicated notes, auto-populated templates, and clinically meaningless flow-sheet entries. Extracting the substance takes both medical training and a disciplined method.

Structured review starts by building a chronology of the clinically significant events: the presenting complaint, the physical findings, the diagnostic workup, the assessments, the treatments, and the response to treatment. The goal is to reconstruct what the treating physicians knew at each decision point and what they did about it. Ancillary noise — nursing task lists, billing codes, routine vital-sign strips — is set aside unless it becomes relevant.

The next layer is comparison to the applicable standard of care. This means identifying the specialty and clinical context, locating the guidelines and literature in force on the date of care, and evaluating whether the treating physicians' decisions fell within the range of reasonable practice. Departures are documented with specificity: which decision, at what point in the encounter, and why a reasonable physician would have done otherwise.

Finally, the review identifies gaps: records that are missing, referenced but not produced, or inconsistent between sources. These gaps often become the most productive discovery targets — a missing operative note, an imaging study referenced in a consult but never subpoenaed, or a nursing entry that contradicts the physician's narrative can reshape the case.

Attorneys who ask 'what do the records show?' get a chronology. Attorneys who ask 'what do the records tell us about the standard of care, causation, and damages?' get a case theory. The difference is the questions posed to the reviewing physician.