The MARTAR Problem: Why Nursing Home Documentation Requires Specialized Data Infrastructure
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There was a moment during a case review demonstration when an attorney said something that crystallized the entire problem: "We can't even get the MARTARs to display correctly in our system."
This wasn't a user error. It was a fundamental mismatch between the data structure these cases produce and the infrastructure most legal technology platforms provide.
MARTAR charts - Medication Administration Records and Treatment Administration Records - represent the evidentiary core of nursing home litigation. They document whether facilities actually implemented the care they committed to providing.
And they present a unique data challenge that traditional document review infrastructure was never designed to solve.
The Format Heterogeneity Problem
The fundamental issue is the absence of standardization across electronic health record systems.
Within a single case, you may encounter:
- Point-Click Care system MARTARs displaying 30-day grid layouts with custom legend systems
- Sigma Care platforms rendering the same information as flowsheet-style progress notes
- Facility-specific formats with idiosyncratic documentation conventions
- Scanned paper records with variable legibility
- Hybrid documentation where routine administration appears as grid notation ("X") but any deviation or comment generates a separate narrative entry
Recently, I examined a case where the header indicated "30-day MARTAR" but the actual grid structure was documenting completely different interventions. The legend promised one categorization system; the implementation used another.
Traditional document review platforms treat these as images or unstructured text. But MARTARs are structured data tables. If you cannot query them as databases, you cannot effectively extract their evidentiary value.
The Scale Problem
Now consider that a moderately complex case might generate 275 potential documentation gaps requiring investigation.
This isn't an outlier. In nursing home cases involving multiple pressure injuries over a 4-6 month facility stay, you routinely see:
- 50+ discrete MARTAR charts
- Covering 6-12 different prescribed interventions
- Spanning 4-6 months of facility care
- Across 2-3 different institutions (accounting for hospital transfers)
- In 3-4 different documentation formats
How do you systematically identify which of those 275 gaps represent meaningful evidence versus routine documentation variation?
The conventional answer: manual review. Match each care plan order to its corresponding MARTAR chart, scan for missing entries, assess relevance to the specific injury being investigated, document findings.
For a single case, this represents 20-40 hours of paralegal time.
The "Turning and Repositioning" Investigation as Case Study
Let me illustrate with a concrete workflow requirement.
Turning and repositioning documentation is frequently dispositive in pressure injury litigation. If a patient develops a stage IV sacral ulcer, establishing whether the facility actually implemented the prescribed two-hour repositioning protocol is often the difference between settlement and dismissal.
Here's the operational workflow this requires:
- Locate the care plan specifying repositioning frequency and method
- Define the critical time period (typically weeks or months around injury onset or progression)
- Identify all relevant MARTAR charts across that timeframe
- Parse each chart for the specific intervention notation
- Flag gaps—missing shifts, absent documentation, patterns suggesting systematic non-compliance
- Cross-reference with wound assessment notes to establish temporal correlation between documentation gaps and injury progression
In one case I reviewed, the care plan remained active throughout March. The corresponding MARTAR chart showed a complete grid structure for daily documentation. Every cell was blank. No staff initials. No notation. Complete absence of documented care.
That's dispositive evidence. But it required three different reviewers before someone identified it, because the MARTAR format was non-standard and the initial reviewers assumed the blank grid indicated a scanning error rather than missing implementation.
Why Traditional Legal Technology Infrastructure Fails Here
Most legal document review platforms optimize for unstructured text: contracts, depositions, email correspondence, medical narrative notes. They're engineered for documents where meaning resides in sentences and paragraphs.
MARTARs operate on different principles:
- They're relational data tables, not text
- Meaning derives from patterns across cells, not individual entries
- Analysis requires cross-document correlation (care plan → MARTAR → clinical assessment → wound progression)
- Absence of data is often more significant than presence (documentation gaps matter more than what was documented)
Attempting keyword search on a MARTAR chart might surface the term "turning" in the legend, but tells you nothing about whether the intervention was actually performed. You need to parse the grid structure, interpret the legend, calculate expected frequency, enumerate documented instances, and identify gaps.
That's not a text search problem. That's a data engineering problem.
The Real-World Consequences
I recently spoke with an attorney from a top firm in New York who was processing nursing home cases using infrastructure designed for medical malpractice. The recurring question: "Why isn't the system capturing MARTAR data accurately?"
The answer: because it wasn't built to. Medical malpractice cases generate operative reports, radiology interpretations, progress notes - narrative documentation.
Nursing home cases generate all of that plus these complex implementation tracking matrices that require entirely different parsing logic and data models.
When you cannot properly structure MARTAR data, you cannot answer the fundamental questions the case turns on:
- Did the facility implement its stated care protocols?
- What is the frequency and pattern of documentation failures?
- What evidence exists of systematic rather than isolated care gaps?
The Components of an Effective Solution
Through analysis of multiple firms' attempts to solve this problem, I've identified the critical infrastructure components:
1. Format-Agnostic Parsing Architecture
The system must recognize Point-Click Care, Sigma Care, and custom formats - extracting the underlying data regardless of visual presentation layer.
2. Relational Data Structuring
Transform grid structures into queryable databases where "Show me all wound care documentation gaps in February" becomes a filter operation, not a manual investigation.
3. Care Plan Linkage Layer
Every MARTAR entry should maintain referential integrity with the originating care plan order. "Daily wound cleansing prescribed. 47 instances documented. 23 expected days with missing documentation."
4. Natural Language Query Interface
Once data is properly structured, questions like "Were there gaps in ointment application during March?" should return answers derived from actual MARTAR documentation, not keyword matching.
The Strategic Context
This matters beyond operational efficiency.
Nursing home litigation protects some of society's most vulnerable populations. The patients in these cases frequently cannot advocate for themselves. They depend entirely on facilities honoring care commitments.
MARTAR charts are the definitive record of whether those commitments were kept.
When attorneys cannot effectively analyze these records, several suboptimal outcomes occur: meritorious cases get declined because key evidence isn't identified; weak cases get pursued because documentation gaps weren't properly evaluated; settlements reflect incomplete understanding of the actual care failures that occurred.
One attorney mentioned that Garry Rhoden passed on a case after determining the pressure wound originated during a hospital stay rather than at the nursing home. With proper data infrastructure, that determination takes 15 minutes. Without it, reaching the same conclusion might require days of manual review - or worse, pursuing litigation against an inappropriate defendant.
The Path Forward
The legal technology industry has developed sophisticated solutions for e-discovery, contract analysis, and case management.
But nursing home litigation requires purpose-built infrastructure that understands these specific documentation formats and supports these specific analytical workflows.
The firms that develop this capability - either through internal development or specialized vendor partnerships - will achieve significant competitive advantage.
Because the MARTAR charts contain the answers. We simply need to build the infrastructure that makes them accessible.
