casemark/med-mal-summary

Medical Malpractice Summary

Produces a structured med-mal case summary from medical records for attorney case evaluation and litigation planning.

Prerequisites

1. Medical records — hospital charts, physician notes, nursing notes, discharge summaries
2. Diagnostic materials — lab results, imaging/radiology reports, pathology reports
3. Procedure documentation — operative reports, anesthesia records, consent forms
4. Pharmacy records — medication administration records, prescription history
5. Patient intake — chief complaint, date of incident, treating providers, patient demographics

Output Structure

1. Case Overview Table

| Field | Content | |---|---| | Patient | Name, DOB, relevant medical history | | Date(s) of alleged negligence | Specific dates | | Facility/Provider(s) | Names, specialties, roles | | Chief complaint / Presenting condition | Initial presentation | | Alleged injury/outcome | Summary of harm | | SOL flag | Statute date + discovery rule considerations |

2. Chronological Care Narrative

For each treatment episode:

| Date | Provider (Specialty) | Clinical Findings | Diagnosis | Treatment/Orders | Outcome/Notes | |---|---|---|---|---|---| | ... | ... | ... | ... | ... | ... |

Flag entries with ⚠ where potential standard-of-care issues exist.

3. Standard of Care Analysis

For each identified deviation:

• Provider: Name and specialty
• Action/Omission: What was done or not done
• Expected standard: What a reasonably competent provider in that specialty would have done
• Supporting basis: Clinical guidelines, protocols, or accepted practice (cite where identifiable)
• Severity: Critical / Significant / Minor

Breach categories to evaluate:

• [ ] Diagnostic errors — missed, delayed, or wrong diagnosis
• [ ] Failure to order appropriate tests
• [ ] Misinterpretation of test results
• [ ] Treatment selection errors
• [ ] Surgical/procedural errors
• [ ] Medication errors (wrong drug, dose, interaction)
• [ ] Failure to obtain informed consent
• [ ] Monitoring failures (post-op, medication, vitals)
• [ ] Premature discharge
• [ ] Failure to refer to specialist
• [ ] Communication failures between providers
• [ ] Documentation gaps or alterations

4. Causation Analysis

For each breach, trace: Breach → Mechanism of Harm → Injury/Outcome

Classify each harm:

| Category | Description | |---|---| | Attributable to negligence | Would not have occurred but for the breach | | Underlying condition | Natural disease progression | | Unavoidable complication | Known risk of necessary treatment | | Concurrent/intervening cause | Other contributing factors |

5. Damages Assessment

| Category | Details | Documentation Source | |---|---|---| | Additional medical treatment | Surgeries, hospitalizations, rehab, future care | Page/record refs | | Physical impairment | Permanent injury, disability, functional limitations | Page/record refs | | Pain and suffering | Duration, severity, ongoing nature | Page/record refs | | Lost wages / Earning capacity | Work restrictions, vocational impact | Page/record refs | | Life expectancy impact | If applicable | Page/record refs |

6. Legal & Evidentiary Flags

• Expert specialties needed — list by specialty based on providers and issues involved
• Statute of limitations — calculate from treatment dates; note discovery rule triggers
• Record red flags — gaps, late entries, alterations, inconsistencies between providers
• Provider admissions — documented apologies, acknowledgments of error, incident reports
• Applicable guidelines — cite specific clinical practice guidelines or hospital protocols implicated
• Strengths — strongest facts supporting liability and damages
• Weaknesses — defenses, contributory factors, documentation gaps undermining the claim

Guidelines

• Cite every factual assertion to specific page numbers, dates, and document sources
• Use medical terminology with parenthetical plain-language explanations on first use
• Present balanced analysis — identify both strengths and weaknesses of the claim
• Do not render legal conclusions on ultimate liability; frame as "potential" breaches for attorney evaluation
• Flag any records that appear incomplete or were not provided
• If standard-of-care analysis requires subspecialty knowledge beyond the records, note that expert consultation is needed
• Mark any cited clinical guidelines or statistics with [VERIFY] unless directly quoted from provided records