Introduction
     Table of Contents
1.  What is the Medical Chart?
2.  Acquiring the Medical Chart
3.  Release of Medical Records
4.  Determining What is Missing From the Medical Chart
5.  How to Examine the Medical Chart
6.  Fact Sheet
7.  Consent Forms
8.  Living Will
9.  Pre-admission Records
10.  Ambulance Call Report
11.  Emergency Department Record
12.  Admission Note
13.  Physician Orders
14.  Progress Note
15.  Consultant’s Note
16.  Anesthesia Note
17.  Procedure Note
18.  Discharge Summary
19.  Radiology Report
20.  Laboratory Report
21.  Autopsy Report
22.  Nursing Note
23.  Medical Policies
24.  Incident Reports
25.  Medication Errors
26.  The Medical Chart as Evidence
27.  Tampering with the Medical Record
28.  Malpractice Issues
29.  Pain and Suffering
30.  Personal Injury Cases
31.  Appendix 1 – Medico-legal Terminology
32.  Appendix 2 – Medical Abbreviations
33.  Appendix 3 – Medical Chart Check Lists
       3.1 – Physician Office Chart
       3.2 – Hospital Chart
       3.3 – Clinic Chart
       3.4 – Missing Items Checklist