Breach & Causation Analysis Worksheet

A structured framework for comparing expected standards of care to actual care delivered and linking deviations to patient harm.

In healthcare negligence cases, identifying a breach of standard of care is only the beginning. The true challenge lies in establishing how that breach directly contributed to the patient’s injury or death. The Breach & Causation Analysis Worksheet provides a structured framework for attorneys to evaluate the key elements of a case, from clinical actions and documentation gaps to timeline events and causation narratives.

This worksheet helps you meticulously assess deviations from established standards of care and connects those deviations to actual harm, creating a defensible pathway for both liability exposure and litigation strategy. Whether you are reviewing case details, preparing for depositions, or building a case strategy, this tool allows you to organize your analysis and map out clear, actionable insights.

By using this worksheet, you will not only strengthen your case but also ensure that you have a comprehensive understanding of how healthcare failures led to patient harm, helping you achieve a more successful litigation outcome.

Define the Standard of Care

Establish the expected standards, required actions, and interventions to clarify what should have been done in the care setting.

Identify Applicable Standards

  • Regulatory requirements
  • Facility policies and procedures
  • Professional guidelines (ANA, CMS, Joint Commission, specialty societies)
  • Manufacturer instructions (devices, medications)
  • Industry norms for similar settings

Expected Actions

  • What should have been assessed
  • What should have been monitored
  • Required interventions
  • Expected communication or escalation

Document What Actually Occurred

Extract key facts from the record to assess what was actually performed versus what was expected.

Key Facts from the Record

  • Assessments performed
  • Vitals documented
  • Interventions provided
  • Provider notifications
  • Medication administration
  • Lab / imaging orders
  • Reassessments
  • Communication with family or caregivers

Gaps in Documentation

  • Missing documentation
  • Contradictory entries
  • Late entries
  • Copy-and-paste documentation
  • No follow-up after abnormal findings

Compare Expected vs. Actual Care

Evaluate the deviation by comparing what should have been done with what actually occurred.

Side-by-Side Evaluation

  • Expected assessment → Actual assessment
  • Expected monitoring → Actual monitoring
  • Expected intervention → Actual intervention
  • Expected communication → Actual communication
  • Expected escalation → Actual escalation

Deviations

  • Missed assessments
  • Delayed interventions
  • Failure to notify provider
  • Failure to escalate
  • Medication errors
  • Unsafe environment not addressed

Identify Breach of Standard of Care

Assess whether the actions or inactions of the provider and facility constitute a failure to meet the standard of care.

Critical Questions

  • Did the provider fail to act as a reasonably prudent clinician would?
  • Did the facility fail to follow its own policies?
  • Were red-flag symptoms ignored?
  • Were required interventions delayed or omitted?

Common Breach Indicators

  • No reassessment after interventions
  • No provider notification
  • Missed or late medications
  • Delayed response to deterioration
  • No documentation of communication
  • Ignoring abnormal labs or vitals

Causation Analysis

Link the breach to the harm and establish whether the breach directly contributed to the injury or death.

Link Breach to Harm

  • What harm occurred?
  • Was the harm foreseeable?
  • Would timely intervention have prevented deterioration?
  • Did delays worsen the condition?
  • Did the breach contribute to death or injury?

Build the Causation Narrative

  • "If X had occurred, Y would likely have been prevented."
  • "The delay in Z allowed the condition to worsen."
  • "Failure to escalate resulted in preventable deterioration."

Timeline Integration

Integrate the breach into the timeline to establish when the failure occurred and its impact on the patient’s condition.

Timeline Integration

  • When did the breach occur?
  • How long was the delay?
  • What happened during the delay?
  • Patient condition before and after the delay

Connecting Breach to Chronology

  • Connecting breach to the chronology strengthens both liability and defense strategy.

Global Red Flags

These are the strongest breach indicators in healthcare negligence matters.

  • Missing documentation
  • Contradictory entries
  • No reassessment
  • No provider notification
  • Delayed escalation
  • Medication discrepancies
  • Ignored abnormal labs or vitals
  • Unsafe environment not addressed
  • No follow-up after new orders

Breach & Causation Analysis Clarifies Liability Pathways

Establishing breach and causation requires more than identifying deviations from standards. It requires demonstrating how those deviations plausibly caused the alleged harm. Our clinical-legal team evaluates standards, policies, timelines, and documentation integrity to determine whether a defensible causal connection exists.

Submit Records for Breach & Causation Analysis