Monthly Archives: June 2013

How Much Time Does it Take to Create a Chronology?

How long does it take to compile a chronology from 5000 pages of medical records? It really does vary with each case. Sometimes a law firm will ask me not to produce a chronology with the goal of saving money; “just focus on xyz”. That is fine for an expert witness, but not for a legal nurse who is responsible for knowing about and explaining the medical issues of a case.  Invariably in a complex case, searching for a piece of data down the road or even later in the week will consume much more time than documenting it in the beginning.  This is true for pdf or paper records.

In medical malpractice, 5000 pages means hospital records and a range of healthcare provider data. Sometimes the sentinel event is clearly defined in a narrow time frame; healthcare prior to that point, while important to know, may be irrelevant to a wrongful death. When I receive a large paper case, the  first thing I do is heave it on the table and begin rapidly sorting into a stack that I know I will not need (but will keep), a stack that does not look important but may become so, and a stack that requires close scrutiny.

I work from the scrutiny pile in detail. Eventually, I will see a reference to something in my “maybe” stack so I return there to pull the page. By now, I have a feel for the case and will spot other important pages to pull. Every piece of paper that I reference in the chronology is retained in a new stack that is now taking shape. When all the data is entered, I sort it chronologically and read it again from a fresh perspective; chronological order makes it easier to identify missing records or redundant care.

I make a copy of that pertinent reference stack for the attorney. Oftentimes, my attorneys do not use or want Bates stamping unless it is mass tort (although it usually makes everyone’s job easier).  Either way, if they do not know the source of data, they or their paralegal will be wasting precious time trying to find it without this copy.

The chronology forms the basis of any research or articles that support, refute, or simply clarify my case.

Only then do I sit down and compose the report, which may only require a few hours initially. I always sleep on my report, re-read it the next morning and again later in the day. I then print it to see possible errors that were not evident on the computer. I repeatedly proof, determine that the ease of readability is appropriate and that the percentage of passive sentences is reasonable. I tweak it to death but I do not charge for this obsessive behavior – perfection is a relative term.

I present the data in a professional folder and off it goes, although the attorney may need the summary report immediately. If so, I protect the file so it cannot be altered and email it in advance.

From personal experience, the average time required to work up a case of this size is ~ 20 hours. The time may be more or less depending upon the event in question.  If the patient died in the first day or week of an event, it takes far less time to document than when tracking health changes over the course of time.

Large or small, the chronology is the basis for medical conclusions that may lay dormant for a year for legal reasons. A year down the road, everyone is grateful for this key document.

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Still looking at those records?

I do not question any MD’s ability to review a medical record; that would be questioning their intelligence. But physicians do not think like nurses. In hospitals, they assess medical conditions; listen to the observations of support personnel, order the care they believe is appropriate, and move on to the next patient.

If all errors arose from the wrong order or a misdiagnosis, then physicians would be excellent in the role of chart review.

When things go wrong, it touches many disciplines. Mistakes are not neatly typed and easily seen in the record – oftentimes they are found in a barely legible note on the corner of a page that does not translate into scanned text.

Physicians rightly assume their orders will be understood and executed, and that the rest of the hospital team – nurses, respiratory therapists, physical therapists, radiologists, pharmacists, wound care specialists, etc., will take care of the patient and assess the effect of what the MD has ordered.

They rely entirely upon nursing staff to report deviations, labs that are out of range, subtle changes in vital signs, breath sounds and condition, unplanned outcomes – in short, everything that the physician is not there to see with his own eyes. If a change in the patient goes unnoticed, whose fault is it? Always the nurse – follow the chain of command from CNA to bedside nurse, charge nurse, even Director of Nursing – mistakes flow uphill.

Who is responsible for charting, medicating, listening to patient and family complaints, ensuring proper nutrition, accurate IV administration and knowing when the I&O indicates fluid overload or the patient is having an adverse reaction to medications or blood, or seeing a discrepancy between a malfunctioning monitor and what the patient exhibits? Who knows when to question a physician’s order and is responsible for calling that doctor and expressing their concern? Who is responsible for knowing every section of a chart and what is missing?

This is what nurses do every day at the bedside. This is not the role of a physician, and a physician cannot see a chart from the perspective of a nurse.

Can Anyone Create a Chronology?

[Encarta Dictionary: English (North America) chro-nol-o-gy (noun) 1. Order of events: the order in which events occur, or their arrangement according to this order.]

This simple definition is what many professionals conceptualize when they think “chronology”. If it were that simple, I could present a high school student with 1000 pages of medical records from physicians, facilities, hospitals, etc., and instruct them as follow:

• Create a basic four column table with headers across the top for the Date, Page Reference, Facility, and Event
• Enter every doctor’s order, every medication given, and the results of all x-rays and lab work.
• Include all vital signs, and every diagnosis that is made along with the physician and date.
• Use a separate row for each type of event and be certain not to miss any of the above.
• Write down the abbreviations and terms as you find them, but do not look them up
• After entering all information, sort by date, spell check your work and review the formatting
• Email the chronology to me within the next ten days

The result would be a 100 page chronology filled with errors and minutiae, faithfully recorded without knowledge of its bearing on the case, deviations from standard of care, definitions of medical terminology, or ability to connect the many dots.

A legal nurse doing the same chronology would be seeing the case unfold in her imagination, having walked those hospital halls, cared for the injured patient with comorbidities, understanding policy and procedure while juggling physicians, ancillary staff and family.

A nurse doing the same chronology would likely produce only 20 pages of data after sifting through the information that is not relevant to the case. There would be a fifth column with observations, definitions, research data and identification of unrelated conditions.

This chronology would be not an endpoint, but merely the first stage of organizing the course of events to allow a pattern to emerge. Only when the pattern of care is established will the inconsistencies become apparent to the medical eye.

Can anyone create a chronology? Yes. Does that make it meaningful? No.

Length does not equal quality, and recitation without filtering is a waste of time, resources, and a client’s money.