Medical records review examines the complete chart to reconstruct what was known, ordered, done, and documented at each point. It identifies gaps, inconsistencies, late entries, and departures from applicable standards.
Reviews are typically performed by legal nurse consultants or physician reviewers and produce a chronology plus an issue analysis.
Alternative Names:
Chart Review, Medical Record Analysis
Why it Matters?
Records review is the foundation of every malpractice defense, and its quality determines whether the case is evaluated accurately. The details that matter are often structural rather than clinical: timestamps showing when a result was actually viewed, late entries added after an adverse event, and orders documented but not carried out. Audit trail data frequently reveals what the printed chart conceals.
Frequently Confused with
Related terms
Frequently asked questions
What does a thorough records review look for?
Who performs the review?
