Upon the completion of the record review...
Every case is unique. A medical malpractice case will likely have exclusive focus on the medical records. A juvenile dependency case stemming from an allegation of wrongdoing, will encompass a broader review of medical, agency, law enforcement reports as well as alternate explanations.
I have included a few example of cases I have worked on, the approximate number of pages reviewed, and the documents I composed for those cases. Clients may request additional summaries, charts or lists that are deemed necessary for their particular case or objective.
The Master Sheet
For every record review I complete, I create a Master sheet. The Master sheet is presented in a Microsoft excel format, allowing the client to filter and isolate specific elements they wish to review. For example; a master sheet typically has hundreds of events, but the client needs to isolate events related to one specific facility. The filter option in excel allows for quick and easy access to a specific year, age or diagnosis.
• The headings on the Master Sheet will be catered to the client's specific needs, some cases require additional headings to document events relevant based on the nature of the review.
• The additional tabs at the bottom of the Master Sheet are also created based on the specifics of the case. This keeps all the information consolidated for easy access and interpretation.
I have included a sample of a Master Sheet below to illustrate how events are documented. Medical reviews are generally complex with more headings and data. If the review is carried out for an attorney, a column including the bates number will be included. Please see sample weight chart as well, excluding any protected information.
• The headings on the Master Sheet will be catered to the client's specific needs, some cases require additional headings to document events relevant based on the nature of the review.
• The additional tabs at the bottom of the Master Sheet are also created based on the specifics of the case. This keeps all the information consolidated for easy access and interpretation.
I have included a sample of a Master Sheet below to illustrate how events are documented. Medical reviews are generally complex with more headings and data. If the review is carried out for an attorney, a column including the bates number will be included. Please see sample weight chart as well, excluding any protected information.
Worked Cases - Work Product
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CIVIL RIGHTS
I. Case - Civil Rights
Shawn A. McMillan, Esq.
Gatlin vs. Contra Costa County
Foster Care
Wrongful death
Neglect in care
Shawn A. McMillan, Esq.
Gatlin vs. Contra Costa County
Foster Care
Wrongful death
Neglect in care
Documents reviewed;
Removal petition, birth records, placement care rates, IEPs (Individual Education Plan), regional center records, DSLs - delivered service logs, HEPs - health education passports, well child appointments, emergency room admissions, coroners report, autopsy photos, medical records from multiple facilities in two counties, CCL - community care licensing, all home health nursing notes.
Total pages reviewed; ~ 17,000
Work product produced;
• Master - Timeline of events from birth to demise comprised of 500 events
• Facility list with corresponding age and LOS - length of stay
• List of CCL complaints for all facilities where the patient resided
• Weight chart from birth to demise
• Bruising evaluation based on photos and nursing notes contained in the medical record
• Summary of emergent medical events that occurred in care
• Summary of care rates for each placement from birth to demise
• Summary of IPP – individual program plans held on annual basis
• Summary of concerns expressed by clinicians as documented in medical records
Removal petition, birth records, placement care rates, IEPs (Individual Education Plan), regional center records, DSLs - delivered service logs, HEPs - health education passports, well child appointments, emergency room admissions, coroners report, autopsy photos, medical records from multiple facilities in two counties, CCL - community care licensing, all home health nursing notes.
Total pages reviewed; ~ 17,000
Work product produced;
• Master - Timeline of events from birth to demise comprised of 500 events
• Facility list with corresponding age and LOS - length of stay
• List of CCL complaints for all facilities where the patient resided
• Weight chart from birth to demise
• Bruising evaluation based on photos and nursing notes contained in the medical record
• Summary of emergent medical events that occurred in care
• Summary of care rates for each placement from birth to demise
• Summary of IPP – individual program plans held on annual basis
• Summary of concerns expressed by clinicians as documented in medical records
II. Case- Civil Rights
Shawn A. McMillan, Esq.
T.T. vs County of San Diego
Foster Care
Abuse in care
Shawn A. McMillan, Esq.
T.T. vs County of San Diego
Foster Care
Abuse in care
Documents reviewed;
Removal, out of care placements, DSL - delivered service logs, psychological evaluations, caregiver notes, clinicians observations, behavioral health; clinic notes, diagnoses, prescribed medication, psychiatric admissions, group home records, conservatorships, court reports, social studies, SIR - special incident reports and all medical records from facilities in multiple states.
Total pages reviewed; ~8,000
Work product produced;
• Master - Timeline of events from birth to adulthood comprised of 550 events
• Facility list with corresponding age and LOS - length of stay
• Summary of invasive/noninvasive medical exams that were conducted while in care
• Summary of injuries and behavioral concerns documented in the medical records
• Summary of outcries/disclosures of abuse by victim
• Summary of concerns expressed by treating clinicians, social workers and guardians
Removal, out of care placements, DSL - delivered service logs, psychological evaluations, caregiver notes, clinicians observations, behavioral health; clinic notes, diagnoses, prescribed medication, psychiatric admissions, group home records, conservatorships, court reports, social studies, SIR - special incident reports and all medical records from facilities in multiple states.
Total pages reviewed; ~8,000
Work product produced;
• Master - Timeline of events from birth to adulthood comprised of 550 events
• Facility list with corresponding age and LOS - length of stay
• Summary of invasive/noninvasive medical exams that were conducted while in care
• Summary of injuries and behavioral concerns documented in the medical records
• Summary of outcries/disclosures of abuse by victim
• Summary of concerns expressed by treating clinicians, social workers and guardians
JUVENILE DEPENDENCY
III. Case -Civil/Dependency
Kevin G. Little, Esq.
Fresno Co. Dept. of Social Services v. V.W. et al.
TPR; Termination of parental rights
Contested TPR and Adoption
WIC §366.26
Kevin G. Little, Esq.
Fresno Co. Dept. of Social Services v. V.W. et al.
TPR; Termination of parental rights
Contested TPR and Adoption
WIC §366.26
Documents reviewed;
Detention, jurisdiction, disposition, status hearings, ex parte orders, selection and implementation reports, laboratory results from birth to detention, photographs of the child upon admission, hospital records upon admission, all radiology interpretations, visit notes by CPS monitors, consistency of visitation, documented FFE - family finding efforts or relative placement.
Total pages reviewed; ~ 4,500
Work product produced;
• Master - Timeline of events from removal to final hearing, including any court hearings, orders or movement of the child's placement (produced in an edit format excel and PDF.)
• Timeline of relative assessment for placement, including dates when specific relatives got live scanned, had home checks, or completed the RFA - Resource Family Approval process.
• Breakdown of all CFT (Child Family Team) meetings, noting changes in case plan goals. Noted when CFT meetings were omitted, when circumstances existed warranting one.
• List of all services parents completed as well as additional certifications obtained
• Flagged list of all discrepancies extracted from the DSL and reports submitted to the court.
Detention, jurisdiction, disposition, status hearings, ex parte orders, selection and implementation reports, laboratory results from birth to detention, photographs of the child upon admission, hospital records upon admission, all radiology interpretations, visit notes by CPS monitors, consistency of visitation, documented FFE - family finding efforts or relative placement.
Total pages reviewed; ~ 4,500
Work product produced;
• Master - Timeline of events from removal to final hearing, including any court hearings, orders or movement of the child's placement (produced in an edit format excel and PDF.)
• Timeline of relative assessment for placement, including dates when specific relatives got live scanned, had home checks, or completed the RFA - Resource Family Approval process.
• Breakdown of all CFT (Child Family Team) meetings, noting changes in case plan goals. Noted when CFT meetings were omitted, when circumstances existed warranting one.
• List of all services parents completed as well as additional certifications obtained
• Flagged list of all discrepancies extracted from the DSL and reports submitted to the court.
IV. Case - Appeal
Pro Per Litigant
Fresno Co. Dept. of Social Services v. L.S.
Fifth Appellate District
Relative Placement
WIC §361.3
Out of County Placement
WIC §361.2(g)4
Pro Per Litigant
Fresno Co. Dept. of Social Services v. L.S.
Fifth Appellate District
Relative Placement
WIC §361.3
Out of County Placement
WIC §361.2(g)4
Documents reviewed;
RFA; Resource Family Approval applications, responses, home study, Fresno County DSS Policy, certificates of completion for RFA orientation, correspondence between client and involved parties.
Pages reviewed; ~ 800
Work Product Produced;
• Master – Timeline of documented placement requests from detention to adoption
• Summary of documents produced to obtain placement with corresponding dates
• Summary of RFA employees client spoke to confirming pending status
• Case law pertaining to grandparent’s rights in the dependency process, obtained through legal research
RFA; Resource Family Approval applications, responses, home study, Fresno County DSS Policy, certificates of completion for RFA orientation, correspondence between client and involved parties.
Pages reviewed; ~ 800
Work Product Produced;
• Master – Timeline of documented placement requests from detention to adoption
• Summary of documents produced to obtain placement with corresponding dates
• Summary of RFA employees client spoke to confirming pending status
• Case law pertaining to grandparent’s rights in the dependency process, obtained through legal research
APPELLATE COURT
V. Case - Appeal
Kevin G. Little, Esq.
Fresno Co. Dept. of Social Services v. V.W. et al.
Fifth Appellate District
TPR; Termination of parental rights
WIC §366.26
Out of County Placement
WIC §361.2(g)4
Due process rights
IAC
Kevin G. Little, Esq.
Fresno Co. Dept. of Social Services v. V.W. et al.
Fifth Appellate District
TPR; Termination of parental rights
WIC §366.26
Out of County Placement
WIC §361.2(g)4
Due process rights
IAC
Documents reviewed;
Full record available on appeal; CT (court transcripts) and RT (recorders transcripts), statements of contested issues, court forms filed during proceedings; JV180, JV285, De-facto parent application, DSS county policy, FFE - family finding efforts procedure.
Total pages reviewed; ~ 2,500
Work product produced;
• List of court reporters on the case during the court proceedings to facilitate augmentation of record filed by the attorney
• List of court hearings counsel assigned to the case missed to assist the appellate attorney in the argument for IAC
• Summary of documented attempts from family and relatives to obtain placement or pursue adoption in the event of TPR
• Case law obtained by conducting legal research to support the argument on appeal
Full record available on appeal; CT (court transcripts) and RT (recorders transcripts), statements of contested issues, court forms filed during proceedings; JV180, JV285, De-facto parent application, DSS county policy, FFE - family finding efforts procedure.
Total pages reviewed; ~ 2,500
Work product produced;
• List of court reporters on the case during the court proceedings to facilitate augmentation of record filed by the attorney
• List of court hearings counsel assigned to the case missed to assist the appellate attorney in the argument for IAC
• Summary of documented attempts from family and relatives to obtain placement or pursue adoption in the event of TPR
• Case law obtained by conducting legal research to support the argument on appeal
VI. Case - Appeal - Juvenile Dependency
Department of Children and Family Services v. J.R.
Pro Per Litigant
Second Appellate District
TPR; Termination of Parental Rights
WIC §366.26
Failure to Protect
WIC §300 (b)
Documents reviewed;
Department of Children and Family Services v. J.R.
Pro Per Litigant
Second Appellate District
TPR; Termination of Parental Rights
WIC §366.26
Failure to Protect
WIC §300 (b)
Documents reviewed;
Documents reviewed;
Original/Amended petitions, Detention,Jurisdiction/Disposition, 6, 12, 18 month review, Adjudication, Contested hearing reports. Case worker notes, affidavits, case plans with respective progress reports, RT (recorders transcript), CT (clerk's transcript), HEP (Health and Education Passport), Medical records; hospital admissions, injury reports. Behavioral Health; therapist assessments and diagnoses (individual/family). Collateral interviews, visitation logs and narratives. Phoenix brief.
Total pages reviewed: ~ 3,000
Work product produced;
• Master – Timeline of events from removal/detainment to adjudication hearing
• Case law obtained by conducting legal research to support the arguments on appeal
• Flagged list of all discrepancies; conflicting dates for court reports, unfounded allegations
• Visitation timeline/ itemized list of; in-person, video and telephone visitation
Original/Amended petitions, Detention,Jurisdiction/Disposition, 6, 12, 18 month review, Adjudication, Contested hearing reports. Case worker notes, affidavits, case plans with respective progress reports, RT (recorders transcript), CT (clerk's transcript), HEP (Health and Education Passport), Medical records; hospital admissions, injury reports. Behavioral Health; therapist assessments and diagnoses (individual/family). Collateral interviews, visitation logs and narratives. Phoenix brief.
Total pages reviewed: ~ 3,000
Work product produced;
• Master – Timeline of events from removal/detainment to adjudication hearing
• Case law obtained by conducting legal research to support the arguments on appeal
• Flagged list of all discrepancies; conflicting dates for court reports, unfounded allegations
• Visitation timeline/ itemized list of; in-person, video and telephone visitation
MEDICAL
VII. Case - Criminal
Pro se Litigant
Aggravated Child Abuse
Metabolic Bone Disorder
Multiple Gestation
Pro se Litigant
Aggravated Child Abuse
Metabolic Bone Disorder
Multiple Gestation
Documents reviewed;
Emergency room assessment, hospital admission, specialty consultations; hematology, orthopedic surgery, genetics, trauma team, expert witness reports, police report and interviews, nursing notes, pain assessments, timing of invasive procedures, photographs of skin discoloration, interpretations by multiple radiologists, physical assessments, ROM of extremities, laboratory values, subsequent hospital admissions, evidence/discovery; hotel receipts establishing care and custody of minor, communication between accused parties.
Total pages reviewed; ~3,000
Work Product Produced;
• Master – Timeline of events from birth, hospital admission, abuse allegations and subsequent admissions/visits.
• Documentation of intrauterine growth restrictions and pregnancy complications
• Timeline of each nursing pain assessment conducted, noting the hour and outcome
• List of every radiology examination, noting the hour, interpretation and interpreting party
• Bruising evaluation based on photographs and clinician notes contained in the medical record
• List of abnormal laboratory results related to bone density; hormone levels, vitamin deficiencies
• Summary of nursing interventions and the technique required to execute them; blood draws, skeletal survey x-ray, intravenous line placement.
Emergency room assessment, hospital admission, specialty consultations; hematology, orthopedic surgery, genetics, trauma team, expert witness reports, police report and interviews, nursing notes, pain assessments, timing of invasive procedures, photographs of skin discoloration, interpretations by multiple radiologists, physical assessments, ROM of extremities, laboratory values, subsequent hospital admissions, evidence/discovery; hotel receipts establishing care and custody of minor, communication between accused parties.
Total pages reviewed; ~3,000
Work Product Produced;
• Master – Timeline of events from birth, hospital admission, abuse allegations and subsequent admissions/visits.
• Documentation of intrauterine growth restrictions and pregnancy complications
• Timeline of each nursing pain assessment conducted, noting the hour and outcome
• List of every radiology examination, noting the hour, interpretation and interpreting party
• Bruising evaluation based on photographs and clinician notes contained in the medical record
• List of abnormal laboratory results related to bone density; hormone levels, vitamin deficiencies
• Summary of nursing interventions and the technique required to execute them; blood draws, skeletal survey x-ray, intravenous line placement.
VIII. Case - Juvenile Dependency
(Case settled prior to trial)
Second Appellate District
Occult Fractures on an immobile child
WIC §300 (e), (a), (b), (j)
Multiple Gestation
(Case settled prior to trial)
Second Appellate District
Occult Fractures on an immobile child
WIC §300 (e), (a), (b), (j)
Multiple Gestation
Documents reviewed;
Birth records, emergency room findings, hospital admission records, radiological work-up and interpretations, laboratory results, vitamin supplementation, expert witness reports, specialist assessments and findings, surgical reports, invasive procedures, medical records from two other facilities, well child visits with the pediatrician, genetic findings, court reports with respective recommendations.
Total pages reviewed: ~12,000
Work product produced;
• Master – Timeline of events from birth to hospital admission
• Weight chart supportive of child following growth curve from birth
• List of every radiology examination, noting the hour, interpretation and interpreting party
• List of every specialist that examined child along with contradicting findings
• List of abnormal laboratory results related to bone density
• Summary of clinical interventions and the technique required to execute them; blood draws, skeletal survey x-ray, line placement.
• Audit of hospital stay noting the inconsistencies in diagnoses, inconclusive findings and interpretations
Birth records, emergency room findings, hospital admission records, radiological work-up and interpretations, laboratory results, vitamin supplementation, expert witness reports, specialist assessments and findings, surgical reports, invasive procedures, medical records from two other facilities, well child visits with the pediatrician, genetic findings, court reports with respective recommendations.
Total pages reviewed: ~12,000
Work product produced;
• Master – Timeline of events from birth to hospital admission
• Weight chart supportive of child following growth curve from birth
• List of every radiology examination, noting the hour, interpretation and interpreting party
• List of every specialist that examined child along with contradicting findings
• List of abnormal laboratory results related to bone density
• Summary of clinical interventions and the technique required to execute them; blood draws, skeletal survey x-ray, line placement.
• Audit of hospital stay noting the inconsistencies in diagnoses, inconclusive findings and interpretations
FAMILY LAW
IX. Case - Civil/Family Court
DVRO, Parentage - Custody and Visitation
3 day trial; RO not granted.
DVRO, Parentage - Custody and Visitation
3 day trial; RO not granted.
Documents reviewed;
DV-100, DV-110, CH-100, Petitioner/Respondent declarations, supplemental reports; additional allegations, Ex-parte orders, temporary custody and visitation orders, visitation monitor reports, testimony at trial, police and incident report narratives.
Total pages reviewed: ~ 400
Work product produced:
• Master – Timeline of events from initial allegation to the filing of the complaint
• Itemized list of allegations; date, location, alleged conduct, correspondence prior to/after
• Flagged list of all discrepancies; conflicting dates for alleged conduct, retracted statements
• Material/questions for cross-examination of accusing party
DV-100, DV-110, CH-100, Petitioner/Respondent declarations, supplemental reports; additional allegations, Ex-parte orders, temporary custody and visitation orders, visitation monitor reports, testimony at trial, police and incident report narratives.
Total pages reviewed: ~ 400
Work product produced:
• Master – Timeline of events from initial allegation to the filing of the complaint
• Itemized list of allegations; date, location, alleged conduct, correspondence prior to/after
• Flagged list of all discrepancies; conflicting dates for alleged conduct, retracted statements
• Material/questions for cross-examination of accusing party
© 2021 by Charting Compliance. All Rights Reserved.
© 2021 by Charting Compliance. All Rights Reserved.