For attorneys and legal nurse consultants testing a chart against the institution's own written rules.
Paste the hospital's policy, protocol or order set on the left (fall prevention, sepsis screening, restraint monitoring, fetal monitoring, post-op vital signs, skin assessment, rapid response, blood administration, anything with a stated frequency, time limit or threshold) and the chart excerpt covering the relevant period on the right. The tool breaks the policy into discrete requirements with their timing or threshold, lists the dated chart events, and lines them up requirement by requirement as met (the chart documents it within the policy's own limit), not met (the chart itself shows it late, missing or different), unclear (the excerpt does not let anyone decide) or not applicable (the policy's trigger is not shown). Every finding is quoted from one of the two texts. It does not say whether care met the standard of care; the institution's policy is evidence of what the institution expected, not the legal standard, and that question is for your expert.
The texts were long and the analysis stopped before the end. Run the policy one section at a time, or the chart one date at a time.
Summary
The policy
Requirements vs. what the chart shows
Chart timeline
Flags
Gaps in what was pasted
How to use the result
Confirm the policy was in force. Compare the policy's effective or revised date to the dates of care. Facilities revise policies often, and a version that post-dates the admission proves nothing about what staff were required to do that day. Request the version in force and its approval history.
Read unclear as a records request, not a clearance. Most rows come back unclear on an excerpt because the flow sheet, assessment form or monitoring strip that would answer the question is not in what you pasted. Each unclear row names what is missing.
Check every not-met row against the full chart. A reassessment missing from the progress notes may sit in a flow sheet, a separate assessment form or a late entry. The EHR audit trail shows when each entry was actually created and by whom.
Policy is not the standard of care. A deviation from the facility's own policy is admissible evidence in most jurisdictions of what the facility expected, but the standard of care is set by expert testimony. Hand the comparison table to the nursing or physician expert rather than treating it as a conclusion.
Look for the policy's dependencies. Policies often reference order sets, scoring tools, appendices or a parent policy. If the text refers to one, request it; the requirement may live there.
Verify every quote against the page it came from before it goes into a chronology, expert packet or deposition outline.
What to request next
The policy version in force on each date of care, with the approval, revision and retirement history and any interim memos or practice alerts
Prior and superseding versions of the policy, and any related protocols, order sets, scoring tools or appendices the policy references
Staffing and assignment records for the shifts in question: unit census, nurse-to-patient ratios, assignment sheets, agency or float staff, charge nurse
Education and competency records showing which staff were trained on this policy, when, and the training content
EHR audit trail for every chart entry cited: user, creation time, edits, late entries, and the device or location used
Complete flow sheets, assessment forms and monitoring data (vital signs, scores, strips, alarm logs) for the period the policy covers
Unit or facility compliance audits, quality or performance-improvement data on this policy, where discoverable
Accreditation survey findings, plans of correction and state survey reports touching the same subject
Need this across the whole chart?
MedLegal AI's Records Analyzer and Timeline Builder read the complete record, pin every finding to a Bates page and build the chronology for the demand or expert packet. Free account to start.