MEDICAL RECORD AUDIT CHECKLIST
A structured, litigation‑ready checklist for identifying documentation gaps, inconsistencies, and deviations from standards of care across all healthcare settings.
Medical records form the backbone of every healthcare negligence case. This checklist helps attorneys systematically review documentation, identify inconsistencies, and uncover deviations from expected standards of care. Use it during case screening, breach analysis, expert preparation, and deposition strategy.
PATIENT & CASE OVERVIEW
✔ Patient Information
• Name
• Age
• Primary diagnosis
• Comorbidities
• Admission date
• Discharge date
• Setting (hospital, LTC, home health, hospice, ALF)
✔ Key Case Dates
• Symptom onset
• Change in condition
• Falls or injuries
• Medication changes
• Transfers or hospitalizations
• Date of death (if applicable)
ADMISSION DOCUMENTATION
✔ Required Records
• Admission assessment
• Baseline vitals
• Medication reconciliation
• Skin assessment
• Fall risk assessment
• Cognitive status
• Functional status
• Safety risks identified
Red Flags
• Missing baseline assessments
• No medication reconciliation
• Contradictory baseline information
• No documentation of caregiver capacity (home health/hospice)Red Flags
• Missing baseline assessments
• No medication reconciliation
• Contradictory baseline information
• No documentation of caregiver capacity (home health/hospice)
DAILY NOTES & ROUTINE CARE
✔ Review for Completeness
• Vitals documented consistently
• Pain assessments
• Symptom monitoring
• Medication administration
Wound care
Therapy notes
ADL assistance (LTC/ALF)
Caregiver education (home health/hospice)
Red Flags
Missing or skipped vitals
Copy‑and‑paste notes
Contradictory entries
Late entries without explanation
No documentation of reassessment after interventions
CHANGE IN CONDITION DOCUMENTATION
✔ Required Elements
Time symptoms changed
Who noticed the change
Assessment performed
Provider notification
Orders received
Interventions performed
Reassessment
Caregiver/family communication
Red Flags
Delayed recognition
Delayed provider notification
No reassessment
No documentation of communication
No follow‑up after new orders
MEDICATION SAFETY REVIEW
✔ Audit for:
Medication list accuracy
High‑risk medications
Missed doses
PRN usage
Side effect monitoring
Medication changes
Pharmacy communication
Controlled substance documentation
Red Flags
Medication discrepancies
Missed or late doses
No monitoring for side effects
No documentation after medication changes
WOUND CARE & SKIN INTEGRITY
✔ Required Documentation
Initial skin assessment
Wound measurements
Dressing changes
Infection signs
Provider notification
Wound care orders
Reassessment
Red Flags
No wound measurements
No progression documentation
No provider notification of deterioratio
FALLS, INCIDENTS & INJURIES
✔ Required Documentation
Time of fall
Witness statements
Assessment after fall
Provider notification
Family notification
Safety interventions
Follow‑up assessments
Red Flags
No documentation of fall
No post‑fall assessment
No safety plan update
COMMUNICATION & ESCALATION
✔ Review for:
Provider notifications
Caregiver/family communication
Interdisciplinary communication
Escalation steps
Response times
Red Flags
No documentation of communication
Delayed callbacks
Provider unaware of deterioration
No escalation despite red‑flag symptoms
DISCHARGE OR TRANSFER DOCUMENTATION
✔ Required Elements
Discharge summary
Medication reconciliation
Follow‑up instructions
Transfer notes
Communication with receiving facility
Condition at discharge
Red Flags
Missing discharge summary
No handoff communication
Contradictory discharge condition
GLOBAL RED FLAGS (ANY SETTING)
Missing documentation
Contradictory entries
Copy‑and‑paste notes
Late entries without explanation
No documentation of communication
No reassessment after interventions
Missing vitals
Missing medication documentation
No documentation of change in condition
No follow‑up after provider orders
These are the strongest indicators of breach across all healthcare environments.