For attorneys and legal nurse consultants working nursing-home and hospital neglect cases.
Paste the wound-care notes, skin assessments, Braden or Norton scores, turning and repositioning logs and MDS excerpts from the record (up to 40,000 characters). The analyzer organizes what the chart literally says into a dated timeline for each wound: first documentation, every measurement, progression, treatment changes and risk scores. It checks whether each documented stage fits the documented tissue description using the NPIAP staging definitions and marks mismatches as documentation inconsistencies to verify with a wound expert. It lists prevention documentation that is present or missing and tells you which records to request next. It does not diagnose, stage or re-stage wounds, and nothing is invented: every date, score and measurement is pulled from your text with a quote.
The record was long and the analysis stopped before the end. Run the later dates as a separate excerpt.
Summary
Wounds
Risk assessments (Braden / Norton)
Prevention documented
Flags
Timeline
Gaps in the record
How to use the result
- Start with first documentation. A wound that first appears in the chart at Stage 3 or 4, unstageable, or as a deep tissue pressure injury, with no earlier Stage 1 or 2 entry, raises the question of what the skin assessments between admission and that date show. Request them.
- Check the stage against the description. Where the tool marks a stage inconsistent with the written tissue description, do not treat that as a conclusion. Give the entries to a wound-care expert (WOCN or physician) for an opinion on what the description supports.
- Read the Braden chart against the care plan. A score of 18 or less is the common at-risk threshold facilities use in their own policies. Compare the dates of at-risk scores to the dates the care plan, turning schedule, support surface and dietary consult changed. Gaps between them are the neglect theory in dates.
- Treat turning-log gaps as a request, not a finding. Missing entries in an excerpt may exist elsewhere in the record (flow sheets, CNA task lists, eMAR). Request the complete logs for the specific shifts listed before relying on the gap.
- Verify every quote against the page it came from before it goes into a chronology, demand letter or expert packet.
What to request next
- Comprehensive care plan and every revision, with dates, for skin integrity and nutrition
- Turning and repositioning logs / CNA flow sheets for every shift in the window
- Complete skin assessment forms from admission through discharge or death
- Wound-care nurse and physician consult notes; wound measurement flow sheets
- Wound photographs with dates (and the facility's photo policy)
- Dietary and dietitian notes, weight records, intake and output, supplement orders, albumin and prealbumin labs
- Support-surface orders and vendor records (specialty mattress, overlay, cushion)
- Incident and occurrence reports; facility-acquired pressure injury investigations
- MDS assessments, Section M (skin conditions), and the CAA worksheets for pressure ulcer
- Staffing records (PBJ data) for the shifts with turning gaps; facility pressure injury prevention policy
Need this across the whole chart?
MedLegal AI's Records Analyzer and Timeline Builder read the complete record (thousands of pages), pin every finding to a Bates page and build the chronology for the demand or expert packet. Free account to start.