Medical Chronology: Sample Case

Prepared by Joel Sahulka, BSN, RN · Plainline Chart Review · Not legal advice
Claimant (fictional)"Patient A," 46-year-old male
Claim typeWorkplace injury, low back
Records reviewed412 pages, 5 providers
Date of injury03/04/2025
Period covered03/04/2025 – 11/20/2025
Citation keyProvider code + page (e.g., ED-12)

Key Findings

  1. Low back pain with right leg radiation was documented on the day of injury, and right foot numbness first appears at the 03/18/2025 follow-up.
  2. An MRI was ordered 03/18/2025, but the record shows no scheduling until it was performed on 05/02/2025, a gap of about six weeks with no documented reason.
  3. Work restrictions in the physical therapy notes (10 lb lift limit) don't match the clinic's work status form from the same week (20 lb).
  4. Surgery was recommended on 06/10/2025. A pre-operative pain score of 8/10 is consistent with the nursing notes in the record.

Chronology

DateProviderEvent and clinical findingsSource
03/04/2025Hollow Creek EDPresents after lifting a 60 lb box at work. Low back pain 7/10 with radiation to the right buttock and thigh. No saddle numbness, bowel and bladder intact. Discharged with NSAID, muscle relaxant, and off-work note for 3 days.ED-3 to ED-9
03/07/2025Maple Ridge Occ. HealthInitial occupational visit. Positive straight-leg raise on the right. Restricted duty, no lifting over 20 lb. PT referral placed.OH-2 to OH-5
03/18/2025Maple Ridge Occ. HealthReports new numbness of right lateral foot. Diminished right Achilles reflex. Lumbar MRI ordered.
New neuro finding		OH-11
03/20 – 04/28/2025Northfield PTEleven PT visits. Pain 6–8/10 with little functional change. PT notes list a 10 lb lift limit.
Restriction mismatch with OH-14		PT-1 to PT-38
04/01/2025Maple Ridge Occ. HealthWork status form continues 20 lb restriction. No mention of MRI status.
MRI not addressed		OH-14
05/02/2025Cedar Valley ImagingLumbar MRI performed. L5-S1 right paracentral disc herniation contacting the S1 nerve root.
~6-week gap from order		IMG-1 to IMG-3
06/10/2025Stonebridge SpineSurgical consult. Failed conservative care. Recommends right L5-S1 microdiscectomy. Pain 8/10.SP-4 to SP-10
07/15/2025Stonebridge SpineMicrodiscectomy performed without complication. Discharged same day.SP-22 to SP-41
11/20/2025Stonebridge SpinePain 3/10, persistent mild right foot numbness. Released to full duty with a home exercise program.SP-88

Open Questions for Counsel

  1. Are scheduling or authorization records available for 03/18 to 05/02/2025 that would explain the MRI delay?
  2. Which restriction was given to the employer, the 10 lb limit or the 20 lb limit?
Sample work product to show format only. A real chronology would cite every entry to the Bates-numbered page and include a full list of records reviewed and records missing.