A medical-care timeline can identify documents and unanswered questions, but it does not establish the standard of care, causation, responsibility, or a claim outcome.

Record the care sequence

  • Symptoms or concerns as documented, date and time, facility, provider, referral source, and record location
  • Appointments, admissions, transfers, tests, procedures, prescriptions, discharge materials, follow-up, and billing documents
  • Names and roles as shown in the records, rather than assumptions based on job titles or facility names
  • Requests made, records received, missing periods, and questions about timeline gaps

Keep terminology separate from conclusions

North Carolina G.S. 90-21.11 contains definitions used in the medical-malpractice statute. Labels in a record can be important to identify, but they do not independently resolve the issues in a matter.

The related medical-care records guide explains how to preserve source documents. A North Carolina medical-malpractice claim requires a fact-specific review.

Source