Medical Records in plain English
Charts, orders, notes, test results, imaging, and billing records.
Where this term may appear
The chart, orders, notes, test results, images, medication records, and other clinical documentation.
What to verify
Preserve the complete source record, including dates, authors, addenda, and related documents, rather than relying on an isolated excerpt of the medical records.
Why context matters
Medical Records may be medically important without deciding whether the applicable legal standard was breached or whether the event caused compensable injury.
Use official and primary sources for current medical, licensing, court, and state-law information.