Medical record summary glossary
Plain definitions of the terms used on this site and in record review work. Legal meanings vary by state and program (workers' comp, auto, disability, liability), so check your jurisdiction before relying on any definition here.
Limits: We have not timed the listed tools on a shared test file: time figures come from the cited studies and vendor pages, and the worked example is synthetic.
Preparing the file
- Source document
- The original record page a fact comes from, as opposed to a summary, chronology or excerpt of it.
- Bates numbering
- A unique, sequential number stamped on every page of a record set, so any page can be cited and found again. Often a prefix plus digits, such as RT-0001.
- Page citation
- The page or Bates number given after a fact in a summary, pointing to the source page that supports it.
- Deduplication
- Finding and setting aside repeat copies of the same page or document, which arrive when records come from several senders. A near copy with a changed addendum is not a duplicate.
- OCR
- Optical character recognition: software that turns scanned or faxed page images into text. Handwriting and poor scans are where it fails most.
- PHI
- Protected health information under HIPAA: health information that identifies a person, held by a covered entity or business associate.
- BAA
- Business Associate Agreement: the HIPAA contract a vendor signs before it handles PHI for you. No BAA, no upload.
Summary formats
- Chronology
- A date-ordered list of every encounter in a file, each with provider, findings, plan and page. Usually the working file a summary is written from.
- Narrative summary
- A prose account of the records, selected for 1 question. Shorter than a chronology and easier to read, harder to check without page citations.
- Hospital course
- The part of a discharge or transfer summary that describes what happened during an admission, usually by problem.
- Pertinent negative
- A normal or absent finding that matters to the question, such as a negative straight leg raise on the last visit. Keep these; leave out unrelated normals.
- Laterality
- Which side of the body a finding or procedure concerns. Left and right flips are a common error in hand and AI summaries alike.
Errors
- Omission
- Something in the records that bears on the question but is missing from the summary. The most common error type in published studies of AI summaries.
- Hallucination
- A statement in an AI-written summary that the source records don't support: an invented date, result, dose or provider.
- Gap in care
- A period with no documented treatment. A summary should note it and any explanation the records give.
Review types and opinions
- IME
- Independent medical examination: an exam by a physician who isn't treating the person, requested by an insurer, employer, attorney or agency to answer specific questions.
- QME
- Qualified medical evaluator: a physician certified by California's Division of Workers' Compensation to perform medical-legal evaluations in disputed claims.
- Peer review
- A records-only review, without an exam, usually of whether specific treatment was reasonable and necessary under named criteria.
- Utilization review
- A payer's review of whether a requested treatment meets its criteria before or after it is given.
- Referral question
- A specific question the client wants the reviewer to answer. The summary is built around them.
- Causation
- Whether, and how far, an event caused the condition. An opinion for the physician, not a fact the summary states.
- Apportionment
- Dividing disability between the event and other causes, such as a pre-existing condition. Why prior history belongs in every IME summary.
- MMI
- Maximum medical improvement: the point where the condition is stable and not expected to change much with treatment. California uses "permanent and stationary".
Questions about the terms
What is the difference between a chronology and a summary?
A chronology lists every encounter in date order with its page. A summary selects what answers 1 question and explains it. You usually build the chronology first.
What is the difference between an omission and a hallucination?
An omission leaves out something the records contain. A hallucination states something the records don't contain. Omissions are more common in AI summaries; hallucinations are rarer but can be serious.
Why do Bates numbers matter in a summary?
They let every fact carry a page citation that anyone can check, which is what makes the summary verifiable and defensible.