Category Archives: LNC Skill Development

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.

A nurse under fire deserves our support whenever possible. But is it always possible, and would you feel like a Benedict Arnold if you testified against another nurse’s care?

Think of it this way: when a person is harmed by negligence, you are not attacking another nurse; you are defending a patient.

Consider this recent case: An elderly woman with Alzheimer’s disease was in hospice and had been minimally responsive for several months. But then her physician decreased her sedation and she began talking with family, responding to her environment, and eating solid food. Her children were delighted with this gift of quality time and even her physician documented the marked change in her behavior. He did not connect the dots that he had overmedicated her (but that is another issue).

One night, a float nurse placed a high dose fentanyl patch on this lady’s chest, who had no order for any type of narcotic and no complaints of pain. Exactly how did that happen?

• Why did the nurse not look for an old patch before placing a new one?
• On whose chart did she document having applied the patch?
• What was the effect on the patient who missed her rightful dose?
• What is this nurse’s work history?
• Did the facility report this event to the State Board of Nursing or Medicare?
• Could this have been an attempted mercy killing?
• Did this act result in permanent damages?

The patch was applied at 9am. At 9:45pm the patient was noted to have fluid-filled lungs and was given atropine, but the patch was not found for another 13 hours. By then it was too late to save her.

I ask you, who monitors pulmonary congestion for 25 hours and doesn’t see a patient’s chest while listening to lungs? If any nurse had looked, she would have found the patch. This case had many unacceptable breaches in care, resulting in death 70 hours after the patch was applied.

What do you think? Is this a family complaint you could get behind? Do you think the nurse’s action resulted in damages that ended in her premature death?

Remember, your job would not be to opine on causation, but to simply and objectively state your understanding of the standard of care in medication administration. Tell the attorney/jury what would constitute good care, and why failure to do so constituted negligence.

You can do that.

I receive numerous requests from nurses that are experienced in their field and wish to find work as testifying experts. This posting is for those nurses.

While there are publications that will list you for a fee, there are free resources to aid in this endeavor.

One of the easiest ways to make contacts is to join a Yahoo group that is active in the medical/legal arena.  LNCExchange is a moderated group in which nurses, physicians, attorneys and other healthcare specialists post questions to the group.  It is a rich resource for experts because we members will put out a call for a particular specialty, which may or may not be geographic-specific. You can then respond directly to that posting.

[Recruiting Expert Witnesses

The BRN Enforcement Program is currently only recruiting qualified registered nurses to review case materials, prepare written opinions, and possibly testify at administrative hearings as an Expert Witness for cases involving Botox/Laser/Dermabraision and HIV/AIDS.

Expert Witnesses are paid $75 per hour for case review and preparation of the expert opinion report and $75 per hour plus expenses if called to testify at an administrative hearing.

If you wish to provide this service to your community and be considered by the BRN as an Expert Witness, please verify that you meet the following requirements:

• A current and active California RN license
• Ten or more years of experience and expertise in one of the areas or specialties listed above AND current employment in that setting
• No prior or current charges or discipline against any health care related license in California or in any other place of licensure

Interesting, no?

At a more general level, when I search for an expert,  I need someone who has been active in their field for 3 of the past 5 years. There are variations on this. If someone has a case in which an event happened during a different timeframe, the attorney may want an expert who was active during that timeframe, particularly if different technology or standards of care were in place at the time.