Medical Record Analysis

When performing a medical record analysis, we will look at the records with a critical eye that considers both sides of the case while keeping an open mind. In addition, we will adhere to the nursing process that defines each patient as unique and requires individual assessments, nursing diagnoses, planning, interventions, and ongoing evaluation and re-evaluation. 

Thus, we will define the standards for the patient and clinical scenarios presented for review while assuring that the time frame pertains to the case is utilized. Our use of published standards will reduce the subjectivity of opinion in the judgments of whether the standard of care was met. 

All reports will include the following: 

• List of Documents Reviewed
• Description of the Events Before Incident
• Definition of the Standard of Care
• Opinion About Whether the Standard of Care was Met or Breached 

Our opinions will be supported by specific nursing behaviors identified for each area of concern with an explanation of the standard of care's relationship to the action.