The TRACE Method

A chronology that lists dates tells you the order of events. A chronology that states significance tells you what each entry demonstrates, what it contradicts, and where the record is silent.

Every TRACE chronology carries a clinical significance column. Entries central to the sequence are marked so counsel can find them without reading 26 pages.

This is the stage that requires clinical judgment, and the stage most record review skips.

Determining when a condition became recognizable means asking what a competent clinician should have seen with the information available at that moment — not with hindsight. It requires having carried diagnostic responsibility, which is why TRACE performs this analysis at the advanced practice level rather than at the level of documentation review.

What the record shows in the gap. Orders placed and not carried out. Notifications documented and not documented. Assessments due and absent. Consultations ordered and never completed.

The absence of an entry is a finding, and it is stated as one.

The clinical relationship between the interval and the outcome — the nature and cause of the injury, which is within the scope of legal nurse consulting practice.

Where an opinion requires physician-level expertise, the report says so explicitly and frames the question for the retained expert rather than answering it. Proximate cause as a legal element is not addressed.

What the record is missing, ranked by expected impact on the clinical analysis, with the custodian for each and what it would establish.

EMR audit trails, institutional policies, staffing records, and pharmacy dispensing data are ordinarily obtained through discovery rather than routine record request. Identifying them is part of the deliverable.