This document is a sample chronological report summarizing the medical records of Amy Johnson relating to a personal injury case. The report was prepared by a legal nurse consultant for John Smith, an attorney. It includes a timeline of key medical events from Amy's birth through her most recent doctor's visit at 9 months of age, including details of her premature birth, time in the NICU and PICU, cranial ultrasound results indicating brain injury, and notes on her developmental delays. The consultant provides analysis and recommendations within the timeline for the attorney to consider regarding the case.

1. 1
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
KM Consulting
Sample Chronological Report Personal Injury
Krystal McMahan, RN, BSN, CLNC
KM Consulting
Phone: (254) 405-3562
Email: krystal.kmconsulting@gmail.com
Confidential Attorney Work Product
April 14, 2014
John Smith
Attorney at Law
Best Law Firm, P.C.
1234 Main Street
Sometown, Texas 12345
Re: Amy Johnson case
Dear Mr. Smith:
Pursuant to your request, I have reviewed Amy Johnson’s medical records for the period
4/12/13 – 1/13/14 including L&D, NICU, EMT, PICU, and pediatric charts; the Johnson’s and
Ms. White’s depositions; and the report from the radiologist expert witness regarding the cranial
ultrasounds. From these records I have generated a chronological timeline from the relevant data.
I have included my comments and recommendations within the chronology for your
consideration.
Thank you for the opportunity to assist in evaluating this case. I will follow up within two
days to answer any questions you may have regarding this case and to determine the next steps
you would like me to take.
Sincerely,
Krystal McMahan, RN, BSN, CLNC

2. 2
Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report format and length. Actual reports will vary in
format and length appropriate to case type and complexity as determined by legal nurse consultant and attorney-client.
Note: For the sake of time and interest, only a sampling of entries has been listed below to demonstrate the format and significance of
the chronological timeline. In an actual case, every single relevant entry would be chronicled to give an accurate picture of the extent
of the injuries and its causes.
Date/Time Source Provider Event Comments
4/12/13
0432
L&D Chart L. Fert, MD Amy born to Scarlett Jones
at Sunnyside Hospital
Born 3 lbs 1.5 oz at 34 wks & 6 days gestation.
4/12/13
0452
NICU Admission
Navigator
N. Port, NNP Amy admitted to NICU Diagnoses: Premature birth 34 weeks, IUGR
4/19/13
0335
Radiology Note D, West, MD Cranial Ultrasound read “insignificant findings”
5/6/13
1002
NICU Discharge
Navigator
N, Nert, RN Amy discharged from NICU Sent home with foster parents (the Johnsons) at
38 wks & 2 days corrected gestational age.
Discharged at 4 lbs. 2 oz., so she would have
required a 4 lbs car seat to go home, however
Amy was sent home in a 5 lbs car seat.
5/20/13
0910
Johnson’s
Deposition
State worker arrived at
Johnson’s house to pick up
Amy
Amy 4 lbs 12 oz at this time and was still put in
the same 5 lbs car seat she was discharged in.
5/20/13
0930
Ms. White’s
Deposition
Ms. White found Amy
unconscious and called 911
Ms. White initiated CPR appropriately for a 5
week old.
5/20/13
0935
EMT Chart C. Reye EMT arrived and
transported Amy to Little
Wonders Children’s Center
The EMT’s assessment of the situation: “the car
seat had been improperly installed in an
upright position instead of at a proper and safe
angle. The infant’s head had flopped forward
within the duration of the twelve minute car
ride”.
5/20/13
0945
PICU Admission
Navigator
C. Kerl, RN Amy admitted to PICU Amy placed on mechanical ventilation and
arterial blood gas (ABG) ordered.
5/20/13
0957
PICU Labs C. May, RT ABG results ABG values were:
pH 7.32 – Normal range is 7.35-7.45
PaO2 67 – Normal range is 80-100 mmHg
PaCO2 67 – Normal range is 35-45 mmHg

3. 3
Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report format and length. Actual reports will vary in
format and length appropriate to case type and complexity as determined by legal nurse consultant and attorney-client.
HCO3 25 – Normal range is 22-26 mEq/L
SaO2 90% - Normal range is 97-100%
All together, these values indicate severe
hypoxemia which means insufficient oxygen in
the blood. Without sufficient oxygen to the
brain, brain tissue injury occurs.
5/20/13
1023
PICU Note B. Goff, MD Amy’s condition assessed. The incident “resulted in positional
asphyxiation including obstruction of the
airway, loss of consciousness, and cardiac
arrest.”
5/21/13
0832
Radiology Note L. Pascal, MD Cranial Ultrasound “Moderate swelling noted as evidenced by loss
of extracerebral space, closure of the Sylvian
fissures, and narrow interhemispheric fissure.”
Brain swelling is an indicator of injury.
5/22/13
0825
Radiology Note L. Pascal, MD Cranial Ultrasound “There is moderate brain swelling with
widespread loss of gray/white matter
differentiation in the parietal and occipital lobes.
There is some diffuse high signal within the
basal ganglia. There are a few areas of cortical
highlighting. There is abnormal low signal in
frontal lobes.”
These findings indicate brain injury.
5/28/13
0817
Radiology Note L. Pascal, MD Cranial Ultrasound “There is now an exaggeration of the normal
gray/white matter differentiation. There is
widespread highlighting of the cortex with low
signal within white matter consistent with
infarction. There is bilateral high signal in
lentiform, globus, and lateral thalami.”
These findings indicate some healing of the brain
injury. It is essential that a radiologist review
these ultrasounds to determine the extent of
damage and the effects on Amy’s development.
This information will be crucial for the life care

4. 4
Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report format and length. Actual reports will vary in
format and length appropriate to case type and complexity as determined by legal nurse consultant and attorney-client.
planner to determine the extent of care Amy will
need throughout her life.
7/11/13
1347
PICU Discharge
Navigator
J, Dawson, RN Amy discharged from PICU Discharge weight 5 lbs 7 oz, appropriate for 5 lbs
car seat.
10/15/13
1130
Pediatric Chart M. Harper, MD Amy’s 6-month check-up “Mother is concerned about infant not meeting
certain developmental milestones. Infant
assessed. Some developmental delays noted even
after correcting for prematurity. Will reassess at
9-month check-up.”
1/13/14
1000
Pediatric Chart M. Harper, MD Amy’s 9-month check-up Several developmental delays noted.
Gross motor: “Per mom, infant still not sitting up
on own or rolling. Slight head lag and rounded
back when pulled to sitting position.” [Gross
motor skills are that of a typical 4 month old.]
Fine motor: “Per mom, still does not reach for
objects but will actively hold objects.” [Fine
motor skills are that of a typical 3 month old.]
Vocalization: “Per mom, coos but does not
babble, make consonant sounds, or laugh out
loud.” [Vocalization is that of a typical 2
month old.]