Disclaimer: This checklist is not meant to be exhaustive or limiting, but is meant to indicate where the physician’s initial reviews will likely be focused. We will be more than happy to call and request additional records if necessary. Similarly, medical record reviews can still proceed without all of the documents listed but may affect the analysis results.
As always, we will be happy to work with you on an individual basis to discuss what records will likely be pertinent to the case.
Pediatric Cases
| Case Type | Suggested Documents |
| General | – Admission notes
– Discharge notes – Consultation notes, if any |
| Prematurity, birth injury, hypoxic-ischemic encephalopathy (HIE)
“The OB docs mismanaged the labor and delivery process and as a result, my baby suffered from (brain damage, broken shoulder, premature birth, and death)” |
– Prenatal records
– Labor and delivery records – Fetal Heart Tracings (FHTs) – NICU records (if any) – Neurodevelopmental records (if any) |
| Pediatric Infectious diseases
“The (pediatrician, ER, urgent care) discharged my baby home and then he/she developed (insert serious disease) and now has experienced (brain damage, chronic organ damage, death)” |
– Initial evaluation (ER, PCP notes, urgent care notes)
– Lab results: blood labs, urine labs, CSF (brain fluid) labs – Progress notes from hospitalization – Discharge notes – Any infectious disease consult notes |
| Pediatric Cardiology
“My baby was born with a heart defect and required surgery. They experienced complications and now the baby had a (stroke, paraplegia, blood clots, intestinal damage)” |
– Pediatric Cardiology notes
– Pediatric Cardiothoracic surgery notes – Echocardiogram results – NICU / PICU / CICU notes – Pediatric Cardiology follow-up outpatient notes |
Surgical Cases
| Case Type | Suggested Documents |
| General | – Admission notes
– Discharge notes – Consultation notes, if any |
| Intraoperative/Postoperative Injury (Anesthesia)
“During the procedure, the patient experienced significant (hypovolemia, hypotension, crash) resulting in severe injury or death.” |
– Admission/Discharge Notes
– Anesthesia preoperative evaluation – Anesthesia flowsheets – Anesthesia postoperative note (PACU) – Note: in many institutions, anesthesia records such as the above are kept independent of the patient’s medical record and need to be specified when requesting patient records |
| Intraoperative/Postoperative Injury (Surgery)
“During the procedure, the surgeon accidentally cut into (insert nearby organ, blood vessel, etc.) resulting in severe injury or death.” |
– Admission/Discharge notes
– Operative notes – Postoperative follow-up notes – Any imaging if applicable – – Any referrals if applicable |
| Postoperative Infection, Wound Dehiscence, Wound Care
“After the procedure, the patient suffered severe infection, necessitating multiple subsequent surgeries, and experienced severe injuries.” |
– Operative notes
– Postoperative notes – Any consult notes (Medicine, Infectious Disease, Plastic Surgery, etc.) – Any subsequent procedure notes – Admission/Discharge notes |
Psychiatry/Neurology
| Case Type | Suggested Documents |
| General | – Admission notes
– Discharge notes – Consultation notes, if any |
| Suicide
“The patient presented to the (ER, outpatient mental health provider, hospital) and voiced suicidal ideation. The patient’s concerns or their family’s concerns weren’t appropriately evaluated and the patient killed himself several days later.” |
– ER or outpatient mental health provider note during the last visit before the suicide
– Psychiatry consult note (suicide risk assessment, discussions with family members) – Last year’s worth of outpatient psychiatry or psychology records, if applicable – Recent inpatient psychiatric admission, if applicable |
| Opioid Overdose
“Patient was being seen by Pain Management over several years, over which his/her prescriptions were increased to extraordinary levels. The patient subsequently overdosed and died.” |
– All pain management records, beginning with the initial assessment
– Any previous substance abuse treatments and records – Pharmacy records indicating the medications and prescribers – Any inpatient treatment records, if applicable |
Internal Medicine
| Case type | Suggested Documents |
| General | – Admission notes
– Discharge notes – Consultation notes, if any |
| Nursing home / Fall / Pressure Ulcer cases
“Failure to monitor patient adequately at nursing home led to the patient’s (fall, fracture, pressure ulcer, death)” |
– Nursing records
– Nursing flowsheets – Wound care consultation notes, if applicable – Attending physician notes and consult notes, if applicable – Hospital admission/discharge notes, if applicable |
| Failure to diagnose acute coronary syndrome (ACS)
“The hospital ER reportedly missed the patient’s heart attack and discharged the patient home. The patient dies from a heart attack several hours or days later.” |
– Emergency Department notes
– Labs, EKG, chest x-ray, or other medical imaging – Medication administration records – Nursing notes, if applicable – Hospital course (coronary tests, echocardiograms, stress testing, EKGs, serial troponins results) – Cardiology consultation notes |
| Failure to diagnose cancer
“Patient was diagnosed with cancer on this date. There was allegedly a delay of some duration. Was there a delay and if so, would an earlier diagnosis make a clinical difference in prognosis?” |
– Outpatient records
– Medical imaging, if applicable – Date of onset of symptoms, date of diagnosis – Staging and type of cancer at diagnosis – Pathology reports – Oncology notes |
OB/GYN
| Case Type | Suggested Documents |
| General | – Admission notes
– Discharge notes – Consultation notes, if any |
| Gynecological Surgery (bowel perforation, ureteral injury)
“During the surgery, the gynecologist accidentally injured the (bowel, ureters).” |
– Outpatient records (not strictly required but provide clinical context)
– Operative notes – Postoperative notes, labs, imaging (if applicable) – Records from subsequent treatment or consultations |
| Failure to diagnose breast cancer
“Patient was diagnosed with breast cancer on this date. There was allegedly a delay of some duration. Was there a delay and if so, would an earlier diagnosis make a clinical difference in prognosis?” |
– Mammogram results
– Outpatient notes – Oncology evaluations and notes |
| Failure to diagnose gynecological cancer (endometrial, uterine, cervical, ovarian)
“Patient was diagnosed with cancer on this date. There was allegedly a delay of some duration. Was there a delay and if so, would an earlier diagnosis make a clinical difference in prognosis?” |
– Outpatient records
– Medical imaging, if applicable – Date of onset of symptoms, date of diagnosis – Staging and type of cancer at diagnosis – Pathology reports – Gynecological oncology notes – Operative notes |
Orthopedic Surgery
| Case Type | Suggested Documents |
| General | – Admission notes
– Discharge notes – Medical imaging, if any – Consultation notes, if any |
| Hip Replacement Surgery
“The patient underwent hip replacement surgery. Postoperatively, the patient experienced (limb length discrepancy, leg misalignment, foot drop, infection, chronic pain). |
– Pre and postoperative imaging (as close to the surgery as possible)
– Operative notes – Preoperative notes – Postoperative notes (inpatient and outpatient) – Consultation notes for the issue at hand (if any, such as Neurology) – Physical therapy notes if a complication occurs at PT
|
| Knee Replacement Surgery
“The patient underwent knee replacement surgery. Postoperatively, the patient experienced (chronic pain, reduced range of motion, infection) |
– Preoperative and postoperative consultation with surgeons
– Preoperative and postoperative imaging – Operative notes – Consultation notes (if any) |
| Bone Fractures
“The patient suffered a fracture and it didn’t heal over correctly.” |
– X-rays of the fracture before and after intervention
– Pertinent medical records only |
Radiology Imaging
To send Radiology imaging directly to Expert iQ:
- Insert CD/USB into your desktop or laptop
- Copy the contents to your computer by right-clicking on the CD drive in your file explorer, selecting Copy, and then right-clicking on the desktop and selecting Paste
- Create a zip folder of the entire contents of the CD by:
- i) On PC: Right-click on folder > Send to > Compressed (zipped) folder
- ii) On Mac: Control click > Compress
- Log into Expert iQ and navigate to the Medical Record Review Engagement
- Scroll down to the Medical Record Review files and upload the ZIP file by dragging, dropping, or browsing your desktop for the ZIP folder
If the file size is still too large, upload Radiology imaging to a file share platform (ShareFile, Dropbox, etc):
- Insert CD/USB into your desktop or laptop
- Copy the contents to your computer by right-clicking on the CD drive in your file explorer, selecting Copy, and then right-clicking on the desktop and selecting Paste
- Create a zip folder of the entire contents of the CD by:
- i) On PC: Right-click on folder > Send to > Compressed (zipped) folder
- ii) On Mac: Control click > Compress
- Navigate to your file share platform
- Drag and drop the ZIP file into the file share platform and create the share link
- The share link can be added to the “Case Summary” or “Questions for Our Physicians” field of an MRR submitted via iQ