Medical record chronology template
Answer in brief: the template below has a 6-line header, 8 columns, a duplicate log and a gap log. Copy the blank version into Excel, Google Sheets or Word with the buttons, or read the filled example first. No email form, no download.
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.
How to use this template
The template has 4 parts, in this order: the header block, the chronology table, the duplicate log and the gap log. Fill the header first, because the citation system you choose there decides what goes in the page column. Then work through the file as described on the step-by-step page.
The copy buttons put tab-separated text on your clipboard. Paste it into cell A1 of a blank spreadsheet and each field lands in its own column. In Word, paste and then use Table, Convert, Text to Table, with tabs as the separator.
Copy a blank part of the template
Nothing copied yet.
Part 1: the header block
| Field | Entry |
|---|---|
| Subject | |
| Date of injury or index event (page) | |
| Referral questions (numbered) | |
| File received (date, source, total pages) | |
| Citation system (PDF page or Bates) | |
| Pages set aside (exact duplicates, non-clinical) | |
| Prepared by, date | |
| Checked by, date |
Part 2: the chronology table
| Date | Time | Provider and facility | Record type | What the record says | Page | Flag | Reviewer comment |
|---|---|---|---|---|---|---|---|
Flag vocabulary: Injury date, Prior, Key finding, Conflict, Copy-forward, Gap, Missing, Undated. The format page says when to use each.
The template filled in on a synthetic file
Synthetic, no real patient. This is the Patient A file from the guide: a 46-year-old warehouse worker referred for an IME after a lifting injury at work. 64 pages, 8 sources, 14 rows.
| Field | Entry |
|---|---|
| Subject | Patient A (synthetic), claim 0000-SYN |
| Date of injury | 2025-03-04 (p. 3) |
| Referral questions | Q1 Diagnosis. Q2 Is the condition caused by the 2025-03-04 event? Q3 Any pre-existing condition? Q4 Is treatment to date reasonable? |
| File received | 2025-11-20, from the referring carrier, 64 pages, 1 PDF |
| Citation system | PDF page of the file as received |
| Pages set aside | 6 exact duplicates (9-14), 4 non-clinical (1-2, 61-62). See the duplicate log. |
| Date | Time | Provider and facility | Record type | What the record says | Page | Flag | Reviewer comment |
|---|---|---|---|---|---|---|---|
| 2022-09-15 | Okafor, R., MD; Eastside Family Medicine | Office note | Low back pain for 2 weeks after yard work. Paraspinal tenderness, negative straight leg raise. Naproxen 500 mg. | 42-44 | Prior | Q3 | |
| 2025-03-04 | 14:20 | Patel, J., MD; Valley General ED | ED note | Lifted a 60-lb box at work, sudden low back pain. "No radicular symptoms." Lumbar strain. | 3-6 (dup 9-12) | Injury date | |
| 2025-03-04 | 15:05 | Valley General radiology | X-ray lumbar | No fracture. Mild degenerative change at L4-5. | 7-8 (dup 13-14) | Q3: degeneration predates? | |
| 2025-03-06 | Lin, S., DO; occupational medicine | Office note | Lumbar strain. Modified duty, no lifting over 10 lb. | 15-18 | |||
| 2025-03-12 | Northgate PT | PT evaluation | Pain 7/10, lumbar flexion limited. Plan 2 visits a week for 4 weeks. | 19-22 | |||
| 2025-03-14 to 2025-04-09 | Northgate PT | PT notes, 8 visits | Pain 7/10 falling to 4/10 by the last visit. | 23-30 | Q4 | ||
| 2025-04-18 | Valley Imaging; signed 2025-04-21 | MRI lumbar | "Broad-based disc protrusion at L4-5 contacting the traversing L5 nerve root." | 31-33 (near-dup 34-36) | Key finding | Q1 | |
| 2025-05-02 | Reyes, M., MD; ortho spine | Consult | "Denies prior back problems." New right leg pain, straight leg raise positive on the right. Plan: epidural steroid injection. | 37-41 | Conflict | See 2022-09-15 | |
| 2025-05-02 to 2025-08-20 | None | Gap, 110 days | No records. Next note: "injection delayed pending authorization." | 45 | Gap | Reason stated | |
| 2025-08-20 | Reyes, M., MD; ortho spine | Follow-up | Persistent right leg pain. Injection scheduled. | 45-49 | |||
| 2025-09-10 | Kim, D., MD; pain management | Procedure | L4-5 interlaminar epidural steroid injection. | 50-53 | Q4 | ||
| 2025-10-15 | Reyes, M., MD; ortho spine | Follow-up | History section identical to 2025-05-02, including "Denies prior back problems." | 54-56 | Copy-forward | Not a new statement | |
| 2025-11-05 | Kim, D., MD; pain management | Follow-up | Partial relief after injection. "Has completed 6 PT sessions at Northside PT." | 57-60 | Missing | Request Northside PT | |
| Undated | Patient; ortho spine intake | Questionnaire, handwritten | Pain diagram marks low back and right leg. | 63-64 | Undated |
Notice what the comment column does. It points rows at referral questions and says what the reviewer will do, but it never restates or interprets the record. The 2025-10-15 row shows why the copy-forward flag matters: without it, a reader might count "denies prior back problems" as 2 separate denials.
Part 3: the duplicate log
| Pages set aside | Duplicate of | Type | Source of the copy | Checked by |
|---|---|---|---|---|
Filled in for Patient A:
| Pages set aside | Duplicate of | Type | Source of the copy | Checked by |
|---|---|---|---|---|
| 9-14 | 3-8 | Exact duplicate | Carrier re-production of the ED file | Page by page, text and stamps match |
| Kept: 34-36 | 31-33 | Near-duplicate | Ortho clinic copy, different header and fax stamp | Text matches; kept because the header shows ortho had the report by 2025-05-02 |
| 1-2, 61-62 | None | Non-clinical | Fax covers, billing ledger | No clinical content |
Part 4: the gap log
| From | To | Days | Type | Evidence (page) | Action |
|---|---|---|---|---|---|
Filled in for Patient A, at a 30-day threshold:
| From | To | Days | Type | Evidence (page) | Action |
|---|---|---|---|---|---|
| 2022-09-15 | 2025-03-04 | 901 | Pre-injury interval | None in file | Ask whether other pre-injury records exist (Q3) |
| 2025-05-02 | 2025-08-20 | 110 | No treatment, reason stated | 45 | None; note in report |
| 2025-09-10 | 2025-10-15 | 35 | Expected follow-up interval | 50-53 (plan: return in 4 to 6 weeks) | None |
| After 2025-11-05 | Records not produced | 57-60 | Request Northside PT notes |
Not every gap is a problem. The 35-day interval after the injection matches the plan in the procedure note. The gap finder calculates these intervals for you from a list of dates.