Adverse Event Chart Review Sample
Adverse event chart review sample for a fictional opioid oversedation on a med-surg unit: every order, PCA entry, vital sign and nursing note in time order with its page, a 3 hour 10 minute gap in charted vitals, 1 late entry and 1 contradiction between the 01:15 nursing note and its 06:52 late entry. A hand-built illustration.
What’s inside this adverse event chart review
- Every order, PCA pump entry, vital sign and note in time order, each with its page
- Gaps in charting, late entries and contradictions flagged, not judged
- A source table that shows where 2 records disagree
- A list of records to request before the root cause analysis meets
| Record set | Fictional post-op PCA oversedation: orders, MAR, PCA pump log, vitals flowsheet, nursing notes, rapid response record, 412 pages |
|---|---|
| Clock | EHR time; both PCA programming events follow their orders |
| Flags | 1 gap in charting of 3 hours 10 minutes, 1 late entry, 1 contradiction |
| Not included | No cause, no policy finding, no standard of care opinion; those are for the risk team and counsel |
This is a hand-built illustration of the Medrecords AI output format on a fictional inpatient event, written for hospital risk management chart review. It was not generated from a real file. Medrecords AI does not decide what caused an event (that is the job of the root cause analysis); it cites and flags the chart entries around it. You review, you revise, you sign.
Sources
The patient, the hospital and every entry in this sample are fictional. The review steps it leaves to the risk team are described here, checked 2026-11-03.
- AHRQ PSNet: Root Cause Analysis primer
- The Joint Commission: Sentinel Event Policy and Procedures
- Hospital risk management chart review, the service this sample illustrates
How Medrecords AI does this work
See how Medrecords AI lays out an inpatient adverse event: every entry cited, gaps and contradictions flagged for the risk team that decides what they mean.
