📚 Teaching Moment: “Am I Missing Records?” (Chronology Review)

Jan Marie

13d • General discussion

Student Question

“I was reviewing the Dropbox files and don’t see ER or Ortho records. Am I missing something?”

The Reality You Must Understand First:

Attorneys are not medical professionals.

They are not trained to:

Organize medical records correctly
Identify what type of record belongs where
Recognize when something is mislabeled or missing

An attorney may genuinely believe:

ER records = PT records
Ortho notes = general follow-ups
Everything important is already included

And they’re not doing anything wrong… they just don’t know.

The Biggest Mistake You Can Make

Assuming something is missing without personally verifying every single file.

This leads to two very real problems:

You build your case on incomplete information

You create your chronology
You start forming opinions
Then later… you find the missing record
Your entire opinion may need to change

You never find it—but opposing counsel does

You go into deposition confident
Opposing counsel pulls out a record you missed
Your credibility is immediately questioned

This happens more often than you think.

Critical Skill: Never Trust File Labels

Files are often:

Misnamed
Misfiled
Combined incorrectly

Example:A file labeled “Physical Therapy” might actually contain:

ER records
Physician notes
Imaging

If you don’t open it… you don’t know.

Advanced Insight Most Nurses Miss

“I don’t need to review billing records”

FALSE.

Some of the most important findings can be hidden in:

Billing summaries
Charge sheets
Line-item entries

What you might find:

A procedure with no physician note
A treatment that was never documented elsewhere
A single line entry that changes the entire case

I have personally found case-changing details buried in billing.

Adopt This Mindset

Assume something is missing or hidden—always.

Not because anyone is intentionally doing something wrong (although sometimes they are), but because:

Systems are messy
Humans make errors
Information gets buried

The U-Haul Story: Why You Never Assume You Have What You Need

I learned this lesson the hard way, and I want you to picture this so you never forget it.

There was a case involving a patient who was injured during surgery. From the injury itself, it appeared the physician was clearly at fault.

The plaintiff attorney requested "any and all" patient medical records.

Now, this patient had been hospitalized for a very long time, including time in the ICU.

Instead of sending the records from the date of surgery forward — the records that actually mattered most — the hospital sent everything.

Not a folder in dropbox.

Not a few boxes.

A literal U-Haul truck filled with medical records.

Every printout.

Every old note.

Every record from the beginning of time for that patient.

There were so many records that the attorney never made it through them all.

And the case was never tried.

Now, could that happen the same way today? Probably not with a Uhaul, BUT...

the lesson is unforgettable:

Important information can be buried—and if you don’t go looking for it, you will miss it.

Your Role as a Legal Forensic Nurse:

You are not just organizing records.

You are:

Investigating
Reconstructing events
Protecting the case

Best Practices Moving Forward

Always:

Open every single file Review every section, even if labeled “billing” Confirm, not assume, what is present or missing Look for:

Missing records
Misfiled documents
Inconsistencies

Communicate clearly with the attorney:

“I have reviewed all files and do not see ER/Ortho records, can you confirm if these exist or if we need to request them?”

Final Takeaway

The difference between an average nurse and a high-level legal forensic nurse is this:

You don’t trust the file system, you trust your review process.

That’s how you protect the case.That’s how you protect your credibility.That’s how you become invaluable.

And as a side note, your practice cases inside the CLFN Program are just the same, I DID NOT ORGANIZE them for you, in fact, I did this on purpose so you could learn hands on and never make the same mistake I did in real time. So, practice this within the practice cases too. Love you!

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