Case Review Checklist: 10 Things I Look For in Every Set of Records
When I open a new set of records, I’m not just reading—I’m scanning for red flags, gaps in care, and moments that can shift the momentum of a case. Over time, I’ve developed a checklist that helps me consistently identify the most critical elements in both plaintiff and defense reviews.
Whether you’re reviewing a claim for merit, preparing for deposition, or working with a medical expert, this checklist ensures nothing gets missed.
📋 10 Things I Look For in Every Case Review
Admission & discharge summaries – Are the key events aligned with the diagnosis and course of care?
Vital sign trends – Are there patterns showing deterioration or delayed response?
Medication timing & administration – Any missed doses or contraindicated meds?
Lab result handling – Were abnormal results acknowledged and acted upon?
Provider communication – Notes that show (or lack) escalation of concerns
Charting inconsistencies – Conflicting documentation between disciplines
Gaps in documentation – Missing notes during critical timeframes
Transfer of care issues – Handoffs that didn’t reflect patient condition
Use of templates or copy/paste entries – Generic language that may mask problems
Unusual delays or deviations – From diagnostics, interventions, or discharges
Reviewing medical records is more than checking boxes—it’s about connecting care patterns with clinical reasoning and legal impact. This checklist is one of the tools I use to bring clarity and confidence to every case I review.
📥 Want a printable version of this checklist?
👉 Download Clear Strategy Case Review Checklist
📅 Ready for a second set of clinical eyes on your case?
👉 Schedule a Case Status Review
