Choose a question, then a resource
The value of a resource is the action it helps you take. Use the reading pages to sharpen a question or organize an investigation; worksheets and additional downloads will be linked as they are released.
For screening, identify what evidence is needed to investigate the allegation. For discovery, focus on the fact that could change the theory. For expert preparation, assemble the relevant sources and the unresolved clinical question.
Choose the related analysis page by that need rather than work through every resource in sequence. Not every matter needs the same depth of review.
A checklist is a starting point, not a universal record list. A hospital transfer, a home health visit, and a long-term care incident generate different documents and involve different responsibilities.
Add the relevant providers, dates, document types, and disputed decisions. Remove irrelevant items without overlooking evidence from another care setting.
Use a working note that distinguishes verified sources, competing accounts, missing information, and the next request. Update it as records and testimony arrive.
Do not turn an unanswered prompt into an allegation. Record who will resolve the question and what evidence would change the assessment.
Illustrative scenario · not a client case
After reading about escalation failures, identify one disputed notification in your file. Note the source showing the concern, the missing communication record, and the witness able to explain the response. The reading has then produced a specific investigation step.
These pages provide educational guidance, not jurisdiction-specific legal advice or a substitute for individual clinical and expert review.
For the underlying methodology, see Clinical Intelligence. General educational information; conclusions about an individual matter require record-specific review.
Use the reading to clarify a question at each stage of the matter, from screening to reassessment of the evidence.
Identify whether a matter has enough breach, chronology, and causation support for deeper review.
Move from scattered records to a clean sequence of events, omissions, and inflection points.
Identify missing records, policies, audit trails, handoffs, incident reports, and communication logs.
Give experts a structured factual and clinical foundation before opinion development.
Build questioning around timing, communication, policy, escalation, and documentation inconsistencies.
Frame the medical record around defensible breach, causation, and value-impact themes.
Define the provider, date range and disputed event first. These starting points explain what to request and why; the appropriate request depends on the individual matter.
Request flowsheets and monitor data, orders and MARs, handoff records and critical-result logs for the same care window.
Compare recognition, notification and response times rather than relying on a discharge summary alone.
Request care-plan versions, MDS assessments, shift notes, MAR/TAR records and incident or wound documentation.
Check whether changing resident needs led to revised interventions and documented follow-through.
Request the plan of care, ordered visit schedule, completed and missed-visit notes, OASIS assessments and communication logs.
Distinguish a missed visit from a refusal or rescheduling, then trace any reported change in condition.
Request election and goals-of-care documents, symptom assessments, medication records and scheduled or on-call visit notes.
Read the response to symptoms in the context of the patient’s documented wishes and plan of care.
Request sending and receiving records, transfer summaries, medication reconciliation and pending-result communications.
Identify what information traveled with the patient and what the receiving team knew at the time.
For large or multi-provider record sets, keep a source register of what was requested, received and still missing. Do not treat an absent document as proof that care did not occur.
A useful reading session should leave you with a better question, a targeted record request, or a clearer issue for expert review. Revisit those notes when new evidence arrives, and revise assumptions that the sources no longer support.
