A medical record can document what was recorded at a point in time, but it does not by itself establish the standard of care, causation, responsibility, or the value of a claim.

Preserve the original record trail

  • Provider and facility names, dates of service, visit summaries, orders, test results, imaging, prescriptions, discharge instructions, and billing documents
  • Messages, appointment logs, referrals, consent documents, notices, and records of requests or responses
  • A dated index that identifies the record source, date received, format, and material that may be missing
  • Questions about terminology, timeline gaps, and document ownership kept separate from conclusions about care

Use statutory terms carefully

North Carolina G.S. 90-21.11 contains definitions used in the medical-malpractice statute. A term in a document may be relevant, but it should be read with the complete record and governing law.

The related health care provider and institution terms guide explains how to identify statutory language in records. A North Carolina medical-malpractice claim requires a fact-specific review.

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