Timing is everything, and a detailed timeline is the first step in analyzing any time-sensitive medical negligence case. Time-sensitive cases are those that allege harm due to delayed diagnosis or treatment of an urgent disease or process. Classic examples include acute myocardial infarction (heart attack), testicular torsion, pulmonary embolism, sepsis, and thrombolytic (TPA) administration in stroke. Entities like these are exquisitely time-dependent, and they require a comprehensive timeline to compile and analyze the course of events.
While attorneys often rely upon case summaries to paint a picture of events, a case timeline is not the same as a case summary. A summary catalogs selected events to provide a global overview of the medical record. It may even provide an interpretation of specific happenings and transcribe handwritten notes. A timeline focuses upon the sequence and timing of events, revealing granular details of chronology that can make or break standard of care and causation. Timelines identify every timed event occurring within a specific window, and provide an overview that is both relative and absolute. When all events are identified and tagged, it builds a foundation for proper case analysis, assures that no events are missed, and allows for quick calculations of elapsed and inter-event time. Consequently, event chronology rather than simple summarization is the key to understanding time-sensitive cases.
Since timelines focus upon events within a specific window, the first step is to identify the window of interest. In medical negligence cases, the window typically opens at the moment that a target action occurred or failed to occur, and closes when there is an incident from the action or inaction. For cases where patient care is highly condensed (e.g. emergency room, outpatient surgery), the entire medical record will be within the window of interest. In situations when patient care is prolonged (e.g. hospitalization, skilled nursing facilities), the window of interest will only excerpt a fraction of the medical record.
Once the target window is defined, the key is to catalog every relevant timed event within the window. If the patient arrived via ambulance, the timeline begins with the first call for help and includes every prehospital event through the moment of arrival at the emergency department. The timeline then focuses upon all subsequent events including all nursing notes, vital signs, physician notes, lab orders, test results, critical events, and disposition. Some events will have several times such as the time that an EKG was ordered and the time it was performed. Manually entered events may have some inconsistency since wall clocks and watches lack synchronization. Nonetheless, every timed event should be displayed in a table with columns for Time, Elapsed Time, and Event. A fourth column is typically added for Comments.
Most attorneys share timelines with their experts in order to facilitate chart review and speed calculations of elapsed time between key events. When sharing a timeline, it is important to omit the Comments column since it must be protected as part of attorney work-product. It is also good practice to include a disclaimer and admonition stating that, “the timeline is provided as a courtesy for case review and not as a substitute for the expert’s full record analysis and independent opinion.”
Armed with a definitive and comprehensive sequence of events, attorneys and their experts will literally be on the same page when analyzing the timing and context of a complex series of events.
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