Reconcile nursing and physician notes, orders, MARs, flowsheets, laboratory results, monitor data, consults, transfer records, audit trails and missing or late documentation.
Establish the admission condition, comorbidities, acuity, functional status, known risks and expected clinical trajectory.
Evaluate relevant radiology reports and available imaging findings, their timing, clinical significance, communication, and relationship to diagnosis, intervention or deterioration.
Rebuild assessment, monitoring, escalation, orders, interventions, transfers and outcomes across departments and shifts.
Compare documented care with the expected response to the patient’s condition, acuity, risk and changing clinical presentation.
Apply relevant facility policies, reporting obligations, accreditation requirements, and applicable federal or state standards.
Determine whether delay, omission, communication failure or system breakdown altered the intervention opportunity or contributed to harm.
Delayed escalation despite deterioration.
Missed abnormal labs or vitals.
Conflicting documentation.
Delayed intervention or consult.
Protocol noncompliance.
Evidence earlier action changes outcome.