Medical records are the evidentiary backbone of healthcare litigation. They document what happened, when it happened, who made the decisions, and why. In a malpractice case, a personal injury claim, a workers’ compensation dispute, or a long-term disability matter, the medical record is often the difference between a strong case and a weak one.
And yet, in my experience working with legal teams across the country, the same mistakes appear with striking regularity. Not because attorneys aren’t thorough — most are extraordinarily thorough — but because medical records are complex clinical documents that require clinical training to interpret accurately.
Here are the five most consequential mistakes I see attorneys make when reviewing medical records, and what to do instead.
1. Treating the Discharge Summary as the Definitive Account
The discharge summary is often the first document an attorney reads and, in many cases, the one they rely on most heavily. It is narrative, organized, and written in plain language compared to the rest of the chart. It feels like the authoritative version of events.
It is not.
Discharge summaries are written — sometimes days after discharge, sometimes by a resident or APP who was not present for key clinical decisions — from memory, from nursing notes, and from other documentation that may itself be incomplete or inaccurate. They are summaries, not transcripts. They reflect the attending physician’s interpretation of events, not a neutral record of them.
The operative note, the nursing flow sheets, the vital sign trends, the medication administration record, and the physician progress notes from the days in question are far more reliable sources of what actually happened at the bedside. Attorneys who anchor their case theory to the discharge summary without cross-referencing these primary documents are building on an uncertain foundation.
What to do instead: Use the discharge summary as an index, not a source. Build your clinical timeline from the contemporaneous primary documents — progress notes, nursing notes, orders, and MAR entries — and then evaluate how accurately the discharge summary reflects them.
2. Misreading Timestamps and Documentation Timing
Electronic health records have created a widespread and consequential misconception: that the time on a note reflects when the clinical event occurred.
It does not. It reflects when the note was entered into the system.
A physician progress note timestamped at 11:47 PM may document an assessment that occurred at 2:00 PM. A nursing note entered at 6:15 AM may describe events from the prior shift. Late entries, addenda, and cosignature timestamps add further layers of complexity. In some EHR systems, the “author time,” “service time,” and “chart time” are three distinct fields that attorneys routinely conflate.
This matters enormously in cases where timing is central — a delayed diagnosis, a failure to respond to a deteriorating patient, a medication error. If the timeline is built from entry timestamps rather than clinical event times, the entire sequence of events may be wrong.
What to do instead: Have a physician reviewer map the clinical timeline using both entry timestamps and documented event times, flagging discrepancies and late entries. In EHR-based records, request metadata if the timing of documentation is a central issue in the case.
3. Overlooking What Is Not There
Attorneys are trained to analyze what the record says. Physicians are trained to notice what the record does not say — and in medicolegal work, the absence of documentation is frequently as significant as its presence.
A progress note that does not document a neurological exam in a patient presenting with headache and hypertension. A nursing note that does not record a response to a pain complaint. An order for a critical laboratory value with no documented physician acknowledgment of the result. A lack of any documentation of an informed consent discussion before a procedure with known serious risks.
These gaps are not accidents. In many cases they represent failures of clinical practice, failures of communication, or deliberate omissions. But they are easy to miss when the focus is on what the record contains rather than what a clinician in that situation should have documented.
What to do instead: Ask your physician reviewer not just to summarize the record but to explicitly identify documentation gaps relative to the standard of care. What should have been documented that wasn’t? What clinical assessments, conversations, or responses are conspicuously absent?
4. Underestimating the Complexity of Medication Records
The medication administration record is one of the most information-dense and consequential sections of any inpatient chart — and one of the most frequently misread by non-clinicians.
Drug names appear in generic and brand form, sometimes interchangeably. Dosing is recorded in units that require clinical context to interpret (mg/kg, units/hour, mcg/min). PRN medications — those given as needed rather than on a schedule — require understanding of the clinical indication and the documentation of patient response. Reconciliation between home medications, inpatient orders, and discharge prescriptions is a common site of error that is invisible without clinical training.
In cases involving medication errors, overdose, underdosing, or drug interactions, an attorney who misreads the MAR may fundamentally mischaracterize what happened — and not discover the error until deposition or trial.
What to do instead: Never interpret the medication administration record without physician review. Even experienced healthcare attorneys should have a clinician verify their reading of medication-related evidence before it becomes part of a case theory.
5. Waiting Too Long to Involve a Physician Reviewer
This may be the most common and most costly mistake of all.
In many legal practices, physician review is treated as a late-stage step — something brought in to prepare an expert report after the case theory is already formed, the complaint is filed, and discovery is underway. By that point, the attorney has spent significant time and resources developing a narrative that a physician reviewer may immediately identify as clinically unsustainable.
Early physician involvement — during case intake, before the complaint is filed — serves a fundamentally different function. It allows the case theory to be built on a clinically accurate foundation. It identifies the strongest and weakest elements of the case before resources are committed. It surfaces issues that may not be apparent from a lay reading of the record but are immediately obvious to a clinician. And it prevents the embarrassment — and the client harm — of pursuing a theory that the defense’s expert will dismantle in the first deposition.
What to do instead: Engage a physician reviewer at the intake stage, not the expert stage. Use that review to screen cases, build your initial timeline, and identify the clinical questions that will drive discovery. The cost of early physician review is a fraction of the cost of late course-correction.
A Note on the Standard of Care
Underlying all five of these mistakes is a common misconception: that the standard of care is a bright line that is either clearly met or clearly violated.
It is not. The standard of care is what a reasonably competent physician in the same specialty, with the same information, in the same clinical context, would have done. It is inherently contextual, specialty-specific, and time-dependent. It requires a physician who understands not just what happened, but what the clinical situation demanded — and whether the response was reasonable given what was known at the time.
Medical records tell you what happened. Physician reviewers tell you what it means.
Working With a Physician Reviewer
Effective medicolegal work is a collaboration between legal expertise and clinical expertise. The best outcomes — for clients, for case preparation, and for the pursuit of justice — come from legal teams that engage physician reviewers early, ask the right questions, and use clinical insight to build cases that are both legally sound and clinically credible.
If your practice handles healthcare litigation, malpractice defense or plaintiff work, personal injury with significant medical components, or long-term disability claims, a physician reviewer is not a luxury. It is a necessity.
Aswani “Ash” Suthrave, MD, MBA, MHA, FACHE is a board-certified physician executive, practicing hospitalist, and Principal of Suthrave & Associates, LLC — a physician-led consulting firm specializing in medicolegal analysis, medical record review, expert witness services, utilization management, and healthcare strategy. He works with plaintiff and defense attorneys, legal teams, and healthcare organizations nationwide.