The medical record is not the medical event.
A conventional record review tells you what the chart says. I investigate how the chart came to say it, testing entries against timestamps, audit trails, metadata, provenance, and the surrounding clinical evidence before treating them as fact.
Attorneys will find everything they expect from a legal nurse consultant here, with an evidence-driven investigative method applied to every engagement.
REQUEST A CASE REVIEW RESEARCH & WHITE PAPERSA chart is evidence about what happened. It is not what happened.
A medical record is built from clinical observations, late entries, imported data, copied content, system processes and, increasingly, artificial intelligence. Each entry has a source, a time it was written, and a history of changes.
I am a registered nurse and legal nurse consultant who has spent more than 11 years building and configuring the EHR systems that generate these records, with graduate training in digital forensics and formal training in investigation.
In practice that means reconstructing chronology, tracing where each entry came from, identifying contradictions and later changes, and establishing what was knowable when a clinical decision was made.
This approach is set out in my published work, beginning with The Record Is Not the Event. Read the research and white papers.
Attorneys
Plaintiff and defense counsel in medical malpractice, wrongful death, personal injury, nursing home, and criminal matters.
Investigators
Private investigators, SIU teams, fraud vendors, Medicaid contractors, and healthcare compliance organizations.
Healthcare Organizations
Hospitals and health systems: risk management, compliance, quality, patient safety, and clinical informatics.
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Consultations are confidential. NDA available on request.
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