Urgent Care Documentation Review & Causation Analysis
Forensic Examination of Medical Records, EMRs, and Triage Logs
In Urgent Care litigation, the "official" provider note often tells only half the story. The widespread use of "templated" Electronic Medical Records (EMRs) can mask the reality of the patient encounter, creating a polished record that contradicts the actual events.
Dr. Max Lebow provides forensic medical record review and causation analysis to uncover the truth hidden within the chart. While many experts rely on summaries, Dr. Lebow reviews every page of the record to identify inconsistencies between the provider's documentation, nursing notes, and the patient's actual condition.
The "Templated Note" Trap
A frequent issue in Urgent Care malpractice is the "auto-normal" physical exam. EMR systems allow providers to click a single button that populates a "normal" exam for every body system, often contradicting the patient's chief complaint.
Dr. Lebow scrutinizes the chart for these "templated" errors:
Contradictions
A chart that documents "patient appearing comfortable and in no distress" while the nursing notes indicate "patient crying in pain" or "vomiting."
The "Impossible" Exam
Documenting a detailed neurological or abdominal exam that likely never occurred given the speed of the encounter.
Focused vs. General
The standard of care requires a focused exam based on the chief complaint. A generic "normal" exam does not meet this standard if the specific area of complaint was not evaluated in detail.
The "Every Page" Methodology
Many experts skim the physician's narrative and ignore the rest. Dr. Lebow believes this is where crucial evidence is lost.
Nursing & Triage Notes
Often the most accurate timeline of the patient's condition. Dr. Lebow analyzes triage logs to determine if delays occurred before the physician even saw the patient.
Vital Sign Flowsheets
"Not heeding an abnormal vital sign" is a common breach. Dr. Lebow tracks the vitals from intake to discharge to see if tachycardia or hypotension was ignored.
Thoroughness
"I look at every medical record to determine if it is a significant part of the outcome... I look at every page."
Causation Analysis: Connecting the Breach to the Injury
Identifying a documentation error is not enough; the error must be the cause of the harm. Dr. Lebow provides detailed causation analysis to determine if the outcome was preventable.
For Plaintiff Counsel
Did the failure to document a negative neurological exam contribute to the missed stroke? Dr. Lebow establishes the direct link between the documentation failure and patient harm.
For Defense Counsel
Dr. Lebow analyzes whether the outcome would have remained the same even with perfect documentation, helping to sever the link of causation.
The "Follow-Up" Failure
The most common documentation error in Urgent Care is the failure to provide time-specific and place-specific follow-up instructions.
Vague Instructions
Dr. Lebow flags instructions like "follow up PRN" as insufficient for high-risk complaints. This type of vague discharge guidance fails to protect the patient.
The Standard
A prudent chart must document exactly when the patient should return and where they should go (e.g., "Return to ER immediately if fever persists").
Get a Forensic Review of Your File
Don't let a templated EMR hide the facts of your case. Retain an expert who digs into the details to find the truth.
Request a Chart Review