Med mal chronology sample: a leak after colectomy
Answer in brief: a chronology for standard-of-care review runs on the clock. Each row gives the event time to the minute, the author's role, and the time the entry was signed, and it reports what the produced chart shows without saying whether anyone fell below the standard. This sample shows 1 night after surgery on a 612-page synthetic file, no real patient.
Limits: Every sample here is synthetic: no real patient, invented names and invented page numbers. Rules quoted for QME and Social Security work come from the cited regulation, read 2026-11-12; they are not legal advice, and facts about other sample libraries come from each publisher's page on that date.
The synthetic file
| Patient | Patient F, 66, elective laparoscopic sigmoid colectomy for recurrent diverticulitis. Invented. |
|---|---|
| Question for the reviewer | Was the response to post-operative changes on the night of 2025-02-12 within the standard of care? |
| File | 612 pages from 1 hospital: operative and anesthesia records, physician notes, orders, nursing notes, vitals flowsheets, medication record, lab and imaging results, ICU records. Not produced: the EHR audit trail and the paging system log. |
| Who reads it | A surgeon reviewing the standard of care, a hospital risk or quality team, or a peer review committee |
The sample standard-of-care chronology
13 rows. "Time" is the event time the record gives. "Signed" is when the entry was signed or filed, shown only where it differs by more than 1 hour.
| Date and time | Author (role) | Type | What the record says | Signed | Page | Note |
|---|---|---|---|---|---|---|
| 2025-02-10 08:05 to 11:40 | A. Romero, MD (attending surgeon) | Operative report | Laparoscopic sigmoid colectomy, stapled anastomosis. "Air leak test negative." | 210-214 | Verbatim | |
| 2025-02-12 07:30 | Surgical resident, PGY-4 | Progress note, day 2 | Tolerating clear liquids. Afebrile, HR 88. "Abdomen soft, appropriately tender." | 240 | Baseline A1 | |
| 2025-02-12 22:00 | RN, surgical floor | Vitals flowsheet | T 38.3 C, HR 112, BP 104/62, RR 22, SpO2 95 percent. | 401 | First change | |
| 2025-02-12 22:15 | RN, surgical floor | Nursing note | "Pt c/o increased abd pain 7/10. On-call resident paged." | 455 | Verbatim A2 | |
| 2025-02-12 22:40 | Surgical resident, PGY-2 (on call) | Telephone order | Acetaminophen 1 g IV; lactated Ringer's 500 mL bolus. No physician note for this contact found in the produced chart. | 302 | Not produced A3 | |
| 2025-02-13 02:00 | RN, surgical floor | Vitals flowsheet | T 38.6 C, HR 124, BP 92/54, RR 26. Urine output 15 mL/h for 2 hours. | 403 | ||
| 2025-02-13 02:10 | RN, surgical floor | Nursing note | "Resident paged x2, states will see pt." | 456 | Verbatim | |
| 2025-02-13 03:15 (drawn), 04:30 (resulted) | Laboratory | Labs | WBC 17.8. Lactate 3.4 mmol/L, flagged high. | 520 | 2 times A4 | |
| 2025-02-13 05:55 | Surgical resident, PGY-2 | Progress note | "Abdomen distended, diffusely tender, guarding." CT ordered. | 2025-02-13 14:12 | 251-252 | Late entry A5 |
| 2025-02-13 07:20 | Radiologist | CT abdomen and pelvis | "Free air and fluid adjacent to the anastomosis, concerning for anastomotic leak." | 530-531 | Verbatim | |
| 2025-02-13 07:45 | RN, surgical floor | Nursing note | "Dr. Romero notified of CT result." | 458 | First attending contact in chart A6 | |
| 2025-02-13 09:30 to 11:05 | A. Romero, MD | Operative report | Exploratory laparotomy. "Anastomotic dehiscence, feculent contamination." Hartmann's procedure. | 216-221 | Verbatim | |
| 2025-02-13 11:30 | ICU attending | ICU admission note | Septic shock. Norepinephrine started. | 260-263 |
Annotations: why each row reads the way it does
- A1, the baseline matters as much as the change. The day-2 morning note sets what "normal" looked like for this patient. Without it, the 22:00 vitals have nothing to be compared with.
- A2, roles, not just names. Standard-of-care questions differ by role: nurse, resident, attending, radiologist. The Author column gives the role on every row, even when the name is unreadable.
- A3, absence is stated carefully. "No physician note found in the produced chart" is a fact about the production. It is not a finding that no one examined the patient. The audit trail or a deposition may answer it.
- A4, labs carry 2 times. The draw time says when the sample was taken; the result time says when the answer was available to the team. Intervals are measured from the second.
- A5, a late entry shows both times. The exam note describes 05:55 but was signed at 14:12, after the return to the OR. The row keeps both. Whether the delay matters, and what the EHR audit trail shows about edits, is for the reviewer and, if needed, a request for the audit log.
- A6, describe the interval, not the conduct. "First attending contact in chart" is accurate to the file. Writing "attending not called overnight" would claim something the file does not prove.
What a standard-of-care chronology adds to a base table
- Clock time to the minute, from flowsheets and orders as well as notes.
- The author's role on every row.
- The signing time when it differs from the event time, so late entries show.
- A list of what was not produced, such as the audit trail and paging logs, in the file header.
- Neutral wording about intervals and absences. The chronology describes; the reviewer judges.
Common misses in med mal chronologies
- Dates without times, which erases every interval the review turns on.
- Only physician notes, leaving out nursing notes and flowsheets where most overnight events live.
- Lab result times without draw times, or the reverse.
- Late entries filed at their event time with no signing time.
- Wording that judges ("failed to", "delayed") in the chronology itself.
Questions about med mal chronology samples
Should a med mal chronology say whether care was below the standard?
No. The chronology reports what the chart shows, with times and sources. The opinion on the standard of care belongs to the reviewing physician.
Why include nursing flowsheets?
Overnight changes in vitals, urine output and pain are usually recorded there first. Physician notes may not exist for those hours at all.