Medical record chronology glossary
Plain definitions of the terms used on this site and in chronology work. Where a term has a legal meaning that varies by state or program, the definition here is the working sense, not the legal one.
Limits: Tool facts come from each vendor's own website, read 2026-11-12, and we have not tested those products. The time figures are published estimates from other sites, cited where used, and the worked example is synthetic.
Terms about the record file
- Addendum
- Text added to a note after it was signed. It gets its own chronology row on the date it was written, flagged as a late entry.
- Bates number
- A unique number stamped on each page of a produced file, often with a prefix. Used as the citation system when a file has one.
- Co-mingled records
- Pages belonging to another patient filed inside this patient's records. Set them aside, note the pages, and don't extract from them.
- Date of service
- The day the patient was seen, the test was done or the procedure happened. The date column of a chronology uses this date, not the signed, transcribed or faxed date.
- Late entry
- A note or addendum written after the encounter it describes. In standard-of-care review, the time between the encounter and the entry can matter.
- OCR (optical character recognition)
- Software that turns a scanned page into searchable text. It struggles with poor handwriting and faint faxes, so pages it can't read need a person.
- Records-reviewed list
- The list of every document reviewed, with source, dates and page range. It often goes into the report as its own section, and it comes from the index you build in step 2.
Terms about duplicates
- Deduplication
- Finding pages that repeat and setting the extra copies aside so each event appears once. Done well, it keeps a log and deletes nothing.
- Duplicate log
- A table that pairs each page set aside with the page it duplicates, the kind of duplicate and who checked it. It lets anyone audit what was left out.
- Exact duplicate
- A page identical to another in text, stamps and handwriting, usually because 2 parties produced the same records.
- Near-duplicate
- A page that matches another except for something small: a header, a fax stamp, a signature date, an added line. It stays in the chronology, because the difference can matter.
- Copy-forward
- Text copied from an earlier note into a new one, common in EHR history and exam sections. Flag it so 1 statement isn't read as 2.
Terms about the chronology
- Medical record chronology
- A date-ordered table of the clinical events in a record file, 1 row per encounter, each citing its source page. It holds no opinion.
- Medical summary
- Prose that pulls the important facts together, often by problem rather than by date. Usually written from the chronology.
- Page citation
- The page or Bates range a chronology row comes from, written so a reader can open that exact page.
- Flag
- A label from a fixed list that marks a row for attention: prior, conflict, gap, missing, undated, copy-forward, key finding, injury date.
- Gap in care
- An interval longer than a chosen threshold with no records. Typed as no treatment, reason stated, records not produced or expected interval.
- Missing record
- A visit, test or provider mentioned in the file whose records are not in it.
- Index event
- The event the review is about: the injury, the surgery, the adverse outcome. Rows are often described as before or after it.
Terms about who reads it
- IME (independent medical examination)
- An examination and report by a physician who is not treating the patient, requested by an insurer, employer or attorney. The chronology supports the history and records sections.
- QME (qualified medical evaluator)
- A physician certified to perform medical-legal evaluations in California workers' compensation. QME reports also list the records reviewed.
- BAA (business associate agreement)
- The HIPAA contract a vendor signs before it handles protected health information for you. Ask for it before uploading any records.