How to Review Medical Records for Cause of Death

TL;DR

To understand the cause of death from medical records, you must first legally obtain the complete set of documents, including physician’s notes, lab results, imaging reports, and hospital admission and discharge summaries. Systematically organize these records chronologically to build a timeline of the patient’s care. Scrutinize the records for inconsistencies, signs of medical negligence, or deviations from the standard of care, paying close attention to the final entries before death. Consulting with a medical expert or a legal professional is often necessary to interpret complex medical terminology and establish a definitive link between the treatment provided and the patient’s passing.

Key Highlights

Legally request and obtain all relevant medical records from every provider.
Organize the documents chronologically to create a patient care timeline.
Identify and analyze key documents like progress notes, medication records, and autopsy reports.
Look for red flags such as medication errors, communication breakdowns, or diagnostic delays.
Cross-reference the official death certificate with the information in the medical chart.
Seek professional assistance from a medical or legal expert for an accurate interpretation.

A person’s medical record is more than just a collection of lab results and prescriptions; it is the official, legal narrative of their healthcare journey. When a life ends under medical care, these documents become the primary source for understanding the sequence of events that took place. In the United States, patient safety experts have raised concerns about the frequency of preventable harm. For instance, a widely cited study from Johns Hopkins Medicine suggested that medical errors could be a significant cause of death, highlighting why families and representatives often seek to examine these records for clarity and answers.

The right to access these sensitive documents is carefully controlled. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes a national standard for protecting individuals’ medical records and other personal health information. For a deceased individual, HIPAA allows a “personal representative,” such as the executor or administrator of the estate, to access the records. State laws may provide additional pathways for next of kin to obtain these files. Understanding these regulations is the first practical step in any review, as access is a prerequisite for analysis.

Obtaining the records is only the beginning. The true challenge is transforming a stack of complex, jargon-filled pages into a coherent story. A methodical review is essential to piece together the timeline, identify critical decision points, and recognize any potential deviations from accepted medical practices. This process involves more than just reading; it requires a structured approach to uncover the facts contained within the chart. The following sections provide a detailed framework for conducting this examination, from organizing the files to knowing when to call for professional help.

The First Step: Legally Obtaining the Complete Medical Record

Before any analysis can begin, you must gather all the necessary paperwork. This process is governed by federal and state laws, and following the correct procedure is essential. A partial record can lead to incorrect conclusions, so the goal is to obtain every document related to the patient’s care from every facility and provider involved.

Who Has the Right to Access Deceased Patient Records?

Under HIPAA, the authority to access a deceased person’s protected health information typically passes to their “personal representative.” This is the individual with legal authority to act on behalf of the deceased person or their estate.

Executor or Administrator: If the deceased person had a will, the named executor is the personal representative. If there was no will, a court will appoint an administrator for the estate. These individuals have the clear legal right to request and receive the full medical record.
Next of Kin: In situations where no personal representative has been appointed, HIPAA may allow family members or other individuals involved in the person’s care or payment for care to access relevant information. However, their access might be limited to information pertinent to their involvement. State laws can vary significantly on this point, with some states granting broader access rights to spouses or adult children.

To exercise these rights, you will need to provide documentation proving your legal standing, such as Letters Testamentary (for an executor) or Letters of Administration.

How to Formally Request Medical Records

Once you have established your legal authority, you can begin requesting the records. This should be a formal, documented process.

Identify All Providers: Make a comprehensive list of every hospital, clinic, primary care physician, specialist, nursing home, and urgent care facility that treated the individual, especially in the period leading up to their death.
Draft a Written Request: Each provider will require a formal written request. Your letter should include:
- The patient’s full legal name, date of birth, and date of death.
- Your full name, contact information, and relationship to the deceased.
- A clear statement that you are requesting a complete copy of the medical record. Avoid asking for a “summary” or “abstract.”
- Your signature and the date.
Provide Necessary Documentation: Along with your request, you must include a copy of the patient’s death certificate and a copy of the legal document proving you are the personal representative (e.g., Letters of Administration). You will also need to provide a copy of your own photo identification.
Follow Up: Healthcare providers are legally required to respond within a specific timeframe, typically 30 days under HIPAA, though state laws may set a shorter period. Keep a record of when you sent each request and follow up by phone if you do not receive a response.

What Constitutes a “Complete” Medical Record?

To conduct a thorough review, you need the entire chart. A complete medical record is extensive and includes many different types of documents. Use this checklist to ensure you have received all the necessary components:

Admission and Discharge Summaries: These provide an overview of a hospital stay, including the reason for admission, the course of treatment, and the final diagnosis. In the case of a death, this will be a death summary.
Physician’s Orders and Progress Notes: These are the day-to-day notes from doctors detailing their observations, thought processes, and treatment plans.
Nursing Notes: Nurses spend the most time with a patient and their notes offer a detailed, minute-by-minute account of the patient’s condition, complaints, and responses to treatment.
Medication Administration Records (MAR): The MAR documents every single dose of medication given to the patient, including the drug name, dose, time, and route of administration.
Lab Results and Pathology Reports: This includes all blood tests, urine tests, tissue biopsies, and other laboratory analyses.
Imaging Reports: These are the written interpretations of X-rays, CT scans, MRIs, and ultrasounds.
Consultation Reports: If specialists (like a cardiologist or neurologist) were called in, their findings and recommendations will be in these reports.
Surgical and Anesthesia Records: For patients who underwent surgery, these records detail every aspect of the procedure.
Emergency Room Records: These documents cover the initial evaluation and treatment if the patient’s final illness began with a visit to the ER.
Autopsy Report: If an autopsy was performed, this report is one of the most critical documents for determining the cause of death.

Organizing the Records for a Chronological Review

Once the records arrive, you will likely have a large, disorganized stack of papers or a folder of digital files. The single most important step in making sense of this information is to organize it chronologically. Medical care is a sequence of events, and understanding the order in which things happened is fundamental to your review.

The Initial Sorting Process

Start by separating the documents into manageable groups.

Group by Provider: Create separate piles or digital folders for each hospital, clinic, or doctor’s office. This prevents records from different facilities from getting mixed up.
Sort by Date: Within each provider’s set of records, arrange every single page in chronological order, from the earliest date to the most recent. Pay close attention to the times listed on the documents, as many critical events can happen within a single day.
Label and Flag Key Events: Use sticky notes, highlighters, or digital bookmarks to mark significant events. This could include the date of admission, dates of surgeries, the first mention of a new or worsening symptom, or any “code blue” or rapid response team activations. This initial flagging helps you quickly locate pivotal moments later.

Building a Master Timeline of Events

With the records sorted, the next step is to create a master timeline. This timeline will serve as the backbone of your entire investigation, pulling information from different documents into one cohesive narrative. You can use a spreadsheet, a legal pad, or a word processing document.

Create columns for the following information:

Date: The date of the event.
Time: The specific time of the event (e.g., 14:30 or 2:30 PM).
Event/Observation/Action: A brief description of what happened (e.g., “Patient complained of chest pain,” “Morphine 4mg administered,” “Dr. Smith consulted”).
Document Source: Where you found this information (e.g., “Nurse’s Note,” “Physician’s Order,” “Lab Report”).
Key Details/Comments: Any important context (e.g., “BP 90/50,” “Oxygen saturation dropped to 85%,” “This was the third complaint of pain in two hours”).

An entry on your timeline might look like this:

Date	Time	Event/Observation/Action	Document Source	Key Details/Comments
03/15/2023	22:05	Patient reported sudden, severe headache (rated 9/10).	Nurse’s Note	Described as “worst headache of my life.”
03/15/2023	22:45	On-call physician paged.	Nurse’s Note	No immediate response noted in chart.
03/16/2023	00:15	Patient found unresponsive. Code Blue called.	Code Blue Record	STAT head CT ordered.
03/16/2023	01:30	Head CT report shows massive subarachnoid hemorrhage.	Imaging Report	Findings communicated to neurosurgery.

This timeline transforms the raw data from the medical chart into a story you can follow. It makes it easy to see delays in care, track the progression of symptoms, and identify moments where a different action might have led to a different outcome.

Identifying and Analyzing Key Documents Within the Chart

While every document in the chart is important, some carry more weight when trying to determine the cause of death. Focusing your initial analysis on these key records can provide the most critical insights and guide the rest of your review.

The Death Certificate: The Official Starting Point

The death certificate is the official government document stating the cause of death. It is usually filled out by the attending physician or a medical examiner. It’s a crucial starting point, but it is not always the complete story.

Structure: The certificate lists an “immediate cause” of death (e.g., cardiac arrest), followed by “underlying causes” that led to the immediate cause (e.g., acute myocardial infarction, which in turn was caused by coronary artery disease). It also has a section for “significant conditions contributing to death.”
Limitations: The physician completing the certificate may not have had all the information available. Without an autopsy, the stated cause can sometimes be an educated guess based on the patient’s clinical presentation. Your review of the full medical record is meant to verify, challenge, or add context to what is written on this certificate.

The Autopsy Report: The Gold Standard

If an autopsy was performed, its report is arguably the most definitive document available. An autopsy is a detailed medical examination of a body after death to determine the cause, manner, and mechanism of death.

What It Contains: The report will include:
- Gross Findings: A description of what the pathologist saw with the naked eye.
- Microscopic Findings: An analysis of tissue samples under a microscope.
- Toxicology Results: A report on any drugs, alcohol, or poisons found in the body.
- Final Anatomic Diagnoses: The pathologist’s final conclusions about the diseases or injuries that caused the death.
How to Use It: Compare the autopsy findings directly with the clinical diagnoses made when the patient was alive. Does the autopsy confirm what the doctors thought was wrong? Or does it reveal a condition that was missed entirely? A discrepancy between the autopsy report and the clinical record is a major point of interest.

Physician’s Progress Notes and Death Summaries

The doctors’ notes provide a window into their thought process. These notes document the patient’s condition, the physician’s assessment, and the plan for treatment on a daily basis.

Differential Diagnosis: Look for the “differential diagnosis,” which is a list of possible conditions the doctor was considering. This shows what they were thinking and what they were trying to rule out.
Treatment Plan: The notes should clearly outline the treatment plan and the reasoning behind it. As you read, ask yourself if the plan seems logical based on the patient’s symptoms and test results.
Death Summary: When a patient dies in the hospital, a physician writes a death summary. This document synthesizes the entire hospital stay, from admission to the final moments. It should provide a concise narrative of the patient’s medical course and state the physician’s opinion on the cause of death. Compare this summary to the timeline you created to check for consistency.

Spotting Red Flags and Potential Medical Errors

As you review the organized records and your timeline, you are looking for more than just a story. You are looking for moments where the care provided may have fallen short of accepted standards. These “red flags” do not automatically prove negligence, but they are areas that warrant closer examination.

Communication Breakdowns

Effective communication is critical in a healthcare setting. Breakdowns can lead to serious patient harm.

Delayed Reporting: Look for instances where a nurse noted a critical change in the patient’s condition (e.g., a drop in blood pressure, a new symptom) but there is a significant delay before a doctor is notified or responds.
Conflicting Plans: Check for disagreements or conflicting orders between different doctors. For example, a consulting specialist might recommend a specific test or treatment, but the primary attending physician does not follow the recommendation. The record should explain why, but sometimes it doesn’t.
Poor Handoffs: Information can be lost during shift changes or when a patient is transferred from one unit to another (e.g., from the ER to the ICU). Look for evidence that the receiving team was not fully aware of the patient’s history or current issues.

Medication Errors

Medication errors are a common and dangerous form of medical mistake. Cross-reference the Physician’s Orders with the Medication Administration Record (MAR).

Wrong Drug or Dose: Was the patient given a medication that was not ordered? Was the dose incorrect?
Administration Errors: Was a medication given at the wrong time or through the wrong route (e.g., intravenously instead of orally)?
Failure to Monitor: Were known side effects of a drug monitored? For example, if a patient was on a powerful blood thinner, were their blood clotting levels checked regularly?
Allergies: Was the patient given a medication to which they had a known allergy listed in their chart?

Diagnostic and Treatment Delays

Time is often a critical factor in treating serious medical conditions. Your timeline is the best tool for identifying delays.

Delayed Diagnosis: How long did it take for doctors to diagnose the problem after symptoms first appeared? For conditions like stroke, sepsis, or heart attack, any delay can be fatal.
Delayed Treatment: Once a diagnosis was made, how quickly was treatment started? For example, in a case of bacterial meningitis, a delay of even a few hours in starting antibiotics can make the difference between life and death.
Failure to Act on Test Results: Look for abnormal lab or imaging results that were not addressed in a timely manner. A critical lab value that is ignored for hours is a major red flag.

Inconsistencies and Altered Records

While rare, medical records are sometimes altered after a bad outcome. Be suspicious of:

Entries written out of chronological order.
Notes that seem overly defensive or self-serving.
Additions or changes made to the record days or weeks after the event. Electronic health records have audit trails that can show exactly when each entry was created and if it was later modified.

Understanding Medical Terminology and Standards of Care

One of the biggest challenges for a layperson is the complex language of medicine. Additionally, to evaluate the quality of care, you need a basic understanding of the legal and medical benchmarks used to measure it.

Decoding Common Medical Abbreviations and Jargon

Medical records are filled with abbreviations and technical terms. While you cannot learn them all, you can look up the most important ones.

Create a Glossary: As you go through the records, keep a running list of unfamiliar terms and abbreviations.
Use Reliable Sources: Use reputable online medical dictionaries like the Merck Manual or MedlinePlus to look up terms. Avoid relying on generic search engine results, which can be inaccurate.
Common Abbreviations to Know:
- SOB: Shortness of Breath
- NPO: Nil Per Os (Nothing by Mouth)
- STAT: Immediately
- PRN: Pro Re Nata (As Needed)
- BP: Blood Pressure
- HR: Heart Rate
- Rx: Prescription/Treatment

What is the “Standard of Care”?

This is a central concept in any medical review. The standard of care is the level and type of care that a reasonably competent and skilled healthcare professional, with a similar background and in the same medical community, would have provided under the circumstances.

It is not about perfection. Medicine is not an exact science, and bad outcomes can happen even with excellent care. The question is whether the provider’s actions were reasonable and appropriate. Did they follow established guidelines and protocols? Did they use their skills and knowledge in a way that another professional in their field would find acceptable? Identifying a deviation from the standard of care is often the key to determining if medical negligence occurred.

Connecting Actions to Outcomes: Proximate Cause

Finding an error is not enough. To be legally and medically significant, that error must have caused or contributed to the patient’s death. This is known as “proximate cause.”

For example, a nurse might have given a Tylenol dose 30 minutes late. While this is technically an error, it is highly unlikely to have caused a patient’s death from a heart attack. However, a four-hour delay in taking a patient with signs of a stroke for a head CT could very well be a proximate cause of their death. Your review should focus on connecting the red flags you find to the ultimate negative outcome.

When to Seek Professional Assistance

A thorough review by a family member can uncover many important facts and provide a degree of clarity. However, there is a limit to what a non-professional can definitively conclude. To get a conclusive answer, especially if you suspect negligence, you will need to consult with experts.

Consulting a Medical Expert

A medical expert can translate the complex medical information into plain English and provide a professional opinion on the quality of care.

Who to Hire: The best expert is usually a practicing physician in the same specialty as the doctor whose care is being reviewed. For example, if the case involves a heart condition, you would want a cardiologist to review the records. Legal nurse consultants are also highly skilled at reviewing charts and identifying potential problems.
What They Do: An expert will review the records and your timeline. They can explain the medical complexities, determine if the standard of care was met, and offer an opinion on whether any identified errors caused or contributed to the death. Their analysis provides the credible, expert backing needed to understand what truly happened.

Engaging a Wrongful Death or Medical Malpractice Attorney

If your review and the opinion of a medical expert suggest that negligence led to your loved one’s death, the next step is to speak with an attorney.

When to Act: There are strict time limits, known as statutes of limitations, for filing wrongful death or medical malpractice lawsuits. These deadlines vary by state, so it is crucial to act promptly.
What an Attorney Does: An experienced attorney understands both the medical and legal complexities of these cases. They have a network of medical experts to call upon, they can handle the legal procedures for filing a claim, and they can represent your family’s interests in seeking accountability. Most of these arizona wrongful death attorneys work on a contingency fee basis, meaning they only get paid if they win the case.

The Value of a Professional Opinion

Even if you are not considering legal action, having a professional review the records can provide immense value. It can offer the peace of mind that comes from knowing that the care provided was appropriate, despite the sad outcome. Alternatively, it can confirm your suspicions and provide a clear, expert-validated explanation of what went wrong. This confirmation is often a critical step for families seeking closure.

Conclusion

Examining a loved one’s medical records to understand their cause of death is a demanding and emotional task. It requires a structured, patient, and detail-oriented approach. The process begins with the legal steps of obtaining the complete record and moves to the analytical work of organizing the information into a chronological timeline. By focusing on key documents like autopsy reports and progress notes, you can begin to piece together the narrative of the patient’s final days. Identifying red flags such as communication failures, medication errors, or treatment delays is central to determining if the care provided met professional standards.

This methodical review can transform a confusing stack of medical documents into a clear sequence of events. It empowers you with knowledge, replacing uncertainty with facts drawn directly from the official record. For many, this process provides essential answers and a sense of closure. For others, it may be the first step toward holding responsible parties accountable for substandard care. The insights gained are invaluable, regardless of the ultimate conclusion.

Do not feel you must complete this journey alone. If your review of the medical records raises more questions than answers, or if you suspect that an error contributed to the outcome, the most important action you can take is to seek a professional opinion. An independent medical expert or a qualified attorney can provide the clarity and guidance needed to fully understand the situation and decide on the right course of action. Given the strict legal deadlines that may apply, seeking this expert consultation promptly is often the most critical step of all. Contact us for free consultation today.

How to Review Medical Records to Understand the Cause of Death