What Should You Send a Medical Consultant for Initial Review?

The short answer: send the records that cover the episode of care in question, the records immediately before and after it, and a brief summary of what the client believes went wrong. A complete file is not required to start, but a clinician can only interpret what is in front of them, and certain gaps can change the answer.

This guide reflects what our clinicians find most useful at the initial review stage. It is not a legal checklist for discovery.

The core records

The episode of care

This is the admission, procedure, visit, or series of visits where the alleged deviation occurred. For a hospital stay, that means the full chart rather than the discharge summary alone. Discharge summaries are written after the fact and often omit the details that matter most.

Nursing documentation

Vital sign flowsheets, nursing notes, medication administration records, and assessment documentation frequently show what the physician notes do not: timing, trends, escalation calls, and whether orders were carried out. We discuss this in more depth in what nursing documentation reveals that physician notes do not.

Imaging and diagnostics

Radiology reports, laboratory results with timestamps, pathology, and monitoring strips. If images themselves are available, note that; some causation questions depend on what an image showed, not only what the report said.

Before and after

Records from the period immediately preceding the episode establish baseline condition. Records after it establish the injury, its trajectory, and current function. Both matter for causation and damages.

Helpful but not essential at the start

Pharmacy records, outside provider records, prior unrelated history, and billing records can usually wait for the initial review unless the issue specifically involves medication, a prior condition, or cost. The reviewer will tell you if they become important.

What to include from counsel

A short note describing the client account, the suspected problem, any statute of limitations pressure, and the specific question you want answered. A focused question tends to produce a focused answer.

What if records are incomplete?

Start anyway when timing matters. A good initial review identifies what is missing, explains why it matters, and states which conclusions depend on it. That list becomes a targeted records request rather than a broad one.

Where this leads

The initial review is the first step of a medical merit screening. If the case moves forward, the same clinicians can keep working the file as new records arrive through clinical case consulting.