An unexpected medical outcome isn’t automatically malpractice. A procedure can carry known risks, a condition can worsen despite appropriate treatment, and records may show that a provider made a reasonable decision based on the information available at the time. That distinction matters, because a claim that can’t be supported by the clinical record won’t survive legal scrutiny. One that can be supported deserves a thorough, early evaluation.
That’s why our review of a medical malpractice claim starts with the medical story, not an assumption about what went wrong. At Berthold Law Firm, PLLC,our full-time, in-house medical consultant examines clinical documentation closely while our attorneys assess the separate legal questions a potential claim involves.
For patients and families in Charleston and across West Virginia, a careful early review can clarify what the records actually support. Contact Berthold Law Firm, PLLC today to schedule a free consultation and review your medical records with our team.
What the Initial Record Review Looks For
The first review focuses on the core facts: what medical problem brought the patient to a provider, which providers were involved, what treatment was given, and what injury is believed to have resulted. A complete account from the patient or family provides context, but the medical records are needed to compare that account with what was documented during care.
Our medical consultant organizes the available information and looks for gaps that may matter. Missing pages, inconsistent timestamps, unexplained changes in a patient’s condition, late entries, and discrepancies between records from separate providers can all point to issues worth investigating further.
Early review may identify:
- Incomplete Records such as absent nursing notes, medication administration records, consultation reports, or discharge paperwork
- Conflicting Documentation such as different accounts of symptoms, communications, assessments, or treatment times
- Key Clinical Questions about why testing, monitoring, referral, treatment, or follow-up did or didn’t occur
- Additional Record Sources including ambulance records, imaging, laboratory results, rehabilitation documentation, and follow-up care
This clinical screening doesn’t decide a case by itself. Our attorneys separately evaluate the legal claim, potential defendants, available evidence, filing requirements, and the provisions of West Virginia Code Chapter 55, Article 7B that govern medical professional liability claims.
How the Medical Timeline Gets Reconstructed
A medical chronology is a date-and-time-ordered account of care drawn from records created by different people and facilities. It turns a large, disorganized chart into a sequence that shows symptoms, assessments, test results, decisions, treatment, and changes in condition. Patterns that aren’t visible when records are reviewed in isolation often emerge from this sequencing.
For a malpractice claim, the chronology often begins before the event in question. Prior health conditions, medications, earlier test results, and previous treatment can affect both the clinical decisions a provider made and whether an alleged error caused a later injury.
Records rarely arrive in one neat package. A hospital chart may contain physician notes, nursing documentation, vital signs, laboratory values, imaging reports, medication records, consultation notes, operative reports, and discharge instructions, while later providers may document complications or recovery progress. The timing of abnormal vital signs, a lab result, a medication dose, or a request for consultation can show when a risk became apparent and what information was available at a particular point in care.
A timeline can help distinguish between an event that was recognized and addressed promptly and one that may have involved a delay in assessment, communication, diagnosis, or treatment. It can also show what happened after the alleged error, which matters when evaluating whether a different course of care could have affected the outcome. That’s one reason we may request records from more than one provider. The relevant story can extend from an initial appointment through hospitalization, discharge, follow-up treatment, and rehabilitation.
How Standard of Care & Causation Are Assessed
The standard of care is the level and type of care a reasonably careful health care provider would deliver under similar circumstances. Reviewing this issue means looking at the patient’s condition at the time, the information available to the provider, relevant clinical practices, and the decisions documented in the chart. The review may examine whether a provider assessed symptoms appropriately, ordered or interpreted tests, communicated significant findings, monitored the patient, carried out treatment, or gave appropriate discharge and follow-up instructions.
Causation asks a separate question: did the departure probably cause or contribute to the injury being claimed? Medical conditions can have multiple causes, including underlying disease, preexisting limitations, treatment risks, and complications that may occur even with appropriate care. A poor result, a known complication, or a disagreement over treatment preferences doesn’t by itself establish malpractice.
In many cases, qualified medical witness testimony is needed to address the applicable standard of care and causation. Our medical consultant helps identify the clinical questions that may require that additional review, while our attorneys determine how the evidence fits the legal requirements.
How Injuries & Damages Enter the Analysis
The records must show more than a possible mistake. They also document the medical consequences that followed: additional procedures, extended hospital stays, new medications, infection, pain management, rehabilitation, reduced function, or future care recommendations. We review records from the period after the alleged event as carefully as the initial treatment records, because follow-up evaluations can reveal whether symptoms improved, persisted, or led to additional diagnoses and ongoing care needs.
Records that may document impact:
- Rehabilitation Records describing therapy goals, functional limitations, and progress over time
- Medication Histories showing new prescriptions, changes in treatment, or ongoing symptom management
- Work Restrictions documenting limits on lifting, standing, driving, or other job duties
- Long-Term Care Recommendations addressing future treatment, assistive devices, or ongoing support
- Follow-Up Evaluations connecting later symptoms and treatment to the patient’s medical course
These clinical facts inform our attorneys’ analysis of economic and noneconomic damages. The value of any claim depends on the evidence, the nature and extent of the injury, applicable law, and other facts specific to the case. It can’t be predicted from a diagnosis or a single record alone.
What Happens After the Initial Evaluation
An initial review may lead to requests for missing records, further factual investigation, or consultation with qualified medical witnesses. In other situations, the available documentation may not support moving forward, even when the patient experienced a serious and upsetting outcome.
West Virginia Code Chapter 55, Article 7B includes procedures that apply before a medical professional liability action may be filed. Section 55-7B-6 addresses prerequisites before filing, including pre-suit notice and a certificate of merit: a statement from a qualified health care provider addressing the basis for the claim. The requirements and timing depend on the circumstances, which makes early record preservation important.
Our in-house medical consultant translates complex clinical documentation into questions our legal team can investigate. Our attorneys then assess legal viability, manage communications and evidence development, and determine whether a claim can proceed under the applicable West Virginia framework.
What a Careful Review Can Tell You
A thorough evaluation separates what the record actually documents from what’s being assumed. It can identify where documentation is incomplete, whether the timeline raises meaningful questions about the care provided, and what evidence may be needed before any legal conclusions can be drawn. Patients and families gain a clearer picture of where they stand before deciding how to proceed.
If you suspect medical negligence in West Virginia, get a clear evaluation of your case. Call Berthold Law Firm, PLLC at (304) 605-2040 for a complimentary consultation.