What a primary care review usually focuses on
Diagnosis, referral, medication, and follow-up. A case review should reconstruct the sequence of history and exam, differential diagnosis, screening, referral, and follow-up of abnormal results from the records available at each decision point.
Five decision points to map
- 1. History and exam
- 2. Differential diagnosis
- 3. Screening
- 4. Referral
- 5. Follow-up of abnormal results
Records that can answer those questions
- Primary Care consultation, procedure, or encounter notes
- Orders and test results used to make the clinical decision
- Medication, monitoring, procedure, or nursing records tied to the event
- Communication with the patient and other specialties
- Later treatment showing the complication, corrected diagnosis, or outcome
Expert and causation questions
- What training and specialty should the reviewing primary care expert have under state law?
- Which of the key decision points in diagnosis, referral, medication, and follow-up is actually being challenged?
- What information was available at that time, not only in hindsight?
- What part of the later harm is attributable to the underlying illness or known risk?
- Would a different medical decision probably have changed treatment or outcome?
Related specialties
Urgent Care Malpractice GuideUrgent Care malpractice questions often require specialty-specific records and expert review.Radiology Malpractice GuideRadiology malpractice questions often require specialty-specific records and expert review.Surgery Malpractice GuideSurgery malpractice questions often require specialty-specific records and expert review.Gynecology Malpractice GuideProcedure, diagnosis, infection, and consent questions.
Use licensing, records, and medical-information sources appropriate to the specialty.