Sample medical chronology
What a nurse consultant delivers: every significant event in order, a source for each, and the key events and gaps flagged. This case is fictional; names, dates and page numbers are invented.
Case
Post-operative sepsis after bowel surgery
A 64-year-old patient develops sepsis on post-operative days 2 and 3 after an elective bowel resection, and is transferred to the ICU in septic shock. Records: 1,140 pages (fictional).
Records reviewed: Inpatient chart, MAR, vital sign flowsheets, lab results with collection times, rapid response note, ICU admission note.
| Date | Time | Source | Event | Nurse reviewer's note |
|---|---|---|---|---|
| Day 0 | 07:42 | OR record p. 112 | Elective laparoscopic sigmoid resection. Uneventful per operative note. Transferred to surgical floor 13:10. | |
| Day 1 | 08:00 | Flowsheet p. 214 | T 37.4 °C, HR 92, BP 128/76, RR 18, SpO2 96% RA. Pain 4/10. | |
| Day 1 | 20:00 | Flowsheet p. 219 | T 38.1 °C, HR 104. Acetaminophen given (MAR p. 301). | Fever and tachycardia: first time two SIRS criteria are documented. |
| Day 2 | 00:00 | Flowsheet p. 221 | No vital signs documented. Order: every 4 hours (Orders p. 88). | Gap: missed vital-sign check. |
| Day 2 | 04:10 | Flowsheet p. 222 | T 38.6 °C, HR 118, BP 102/60, RR 24. Patient "restless." | Key event: meets sepsis screening criteria (qSOFA 2). No screen or escalation documented. |
| Day 2 | 04:30 | Nursing note p. 405 | "Patient resting. Will continue to monitor." | No provider notification documented. |
| Day 2 | 07:15 | Nursing note p. 407 | Day-shift RN notes abdomen distended, urine output 120 mL over 8 h. Page to surgical resident. | Key event: first escalation, about 3 hours after criteria were met. |
| Day 2 | 07:50 | Orders p. 92 | Lactate, CBC, blood cultures ×2, 1 L LR bolus ordered. | |
| Day 2 | 09:05 | Lab p. 512 | Lactate 3.4 mmol/L (collected 08:40). WBC 18.2. | |
| Day 2 | 10:20 | MAR p. 309 | Piperacillin-tazobactam first dose. | Antibiotics about 2.5 hours after the order set; compare with the hospital sepsis policy (request). |
| Day 2 | 14:00 | Flowsheet p. 226 | BP 88/50, HR 126. Second bolus given. | |
| Day 2 | 15:35 | Rapid response note p. 433 | RRT called for hypotension. MAP 58. | Key event. |
| Day 2 | 16:40 | ICU admission p. 610 | Admitted to ICU, septic shock, norepinephrine started. CT: anastomotic leak. | Key event. |
| Day 2 | — | — | Night-shift nursing note for 00:00–04:00 not found in production. | Missing record: request the audit trail for the flowsheet and any late entries. |
Key event Gap or missing record
Gaps and records to request
- Vital signs due at 00:00 on Day 2 not documented (flowsheet p. 221)
- No sepsis screen documented when criteria were met at 04:10 (hospital policy not produced)
- No provider notification documented between 04:10 and 07:15
- EHR audit trail for night-shift entries not produced
- Rapid response team criteria and activation policy not produced
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