Medical Harm Timeline & Record Organizer

Patient Information

Patient Name (Optional)

Date of Birth

Age at Time of Incident

Relationship to patient

Gender

Male Female Nonbinary Prefer not to say

Person Completing This Form

Patient Parent Spouse/Partner Adult Child

Other

Name of person completing form (Optional)

Phone (Optional)

Email (Optional)

Hospital Information

Name of Hospital

City/State

Dates of Hospitalization

Type of Admission (Check all that apply)

Emergency Room Visit Inpatient Admission Surgery Labor & Delivery Psychiatric Admission ICU Admission Transfer From Another Hospital

Other

Department(s) Involved (Check all that apply)

Emergency Department Intensive Care Unit (ICU) Medical/Surgical Floor Behavioral Health/Psychiatry Labor & Delivery Surgery/Operating Room Recovery Room Telemetry/Cardiac Unit Rehabilitation

Other

What Happened?

Why was the patient originally admitted?

What was the most serious and harmful event? (Check all that apply)

Delay in treatment Failure to diagnose Wrong diagnosis Medication error Surgical error Infection acquired in hospital Fall Pressure sore/bed sore Failure to monitor patient Failure to respond to emergency symptoms Unsafe discharge Patient left unattended Failure to supervise staff or resident physicians Failure to transfer patient appropriately EMTALA violation concerns Mental health patient abandonment Dehydration/malnutrition concerns Sepsis concerns Respiratory distress ignored Bleeding concerns Delayed surgery/procedure Physical restraint concerns Suicide/self-harm incident Unexpected death

Other

Outcome

Outcome (Check all that apply)

Temporary injury Permanent injury Brain injury Organ damage Paralysis Emotional trauma Additional surgeries required ICU admission required Extended hospitalization Readmission to hospital Death

Other

Date of Injury or Death

Doctors and Staff

Names of Doctors Involved (Optional)

Names of Nurses or Other Staff Involved (Optional)

Did any staff member say something that concerned you?

Yes No

If yes, describe

Warning Signs & Concerns

Did the patient or family warn staff that something was wrong?

Yes No

Were concerns ignored or minimized?

Yes No

Which concerns were raised? (Check all that apply)

Severe pain Difficulty breathing Confusion/change in mental status Bleeding Falling blood pressure Fever/infection symptoms Suicidal thoughts Unable to walk Not eating/drinking Unsafe discharge concerns Medication reaction

Other

How did staff respond?

Discharge & Follow-Up

Was the patient discharged unexpectedly or too early?

Yes No

Was the patient discharged to:

Home Nursing facility Rehabilitation center Homeless shelter Hotel/motel Street/sidewalk/public area Another hospital Unknown

Other

Was the patient able to safely care for themselves at discharge?

Yes No Unsure

Did staff explain discharge instructions clearly?

Yes No

Medical Records & Evidence

Have you requested medical records?

Yes No

Do you currently possess: (Check all that apply)

Hospital records Billing records Death certificate Autopsy report Photographs Video/audio recordings Text messages/emails Government investigation reports Witness statements

Other

Complaints

Have complaints been filed with: (Check all that apply)

Hospital administration State health department Medical board Nursing board CMS Accreditation organization Law enforcement Attorney contacted Lawsuit filed No complaints filed yet

Additional details (Optional)

Timeline of Events

Please briefly describe the sequence of events in your own words.

Additional Concerns

Did you observe any of the following? (Check all that apply)

Understaffing Staff appearing overwhelmed Delayed responses to call lights Conflicting information from staff Missing documentation Records that appeared inaccurate Staff arguing or confused Unsanitary conditions Lack of physician supervision Patient wandering/elopement concerns Security concerns Staff discussing cover-up concerns

Other

Final Comments

Is there anything else you believe is important?

Date