Which records should you upload for a med mal review?
For a med mal review, upload the full chart for the care at issue. Add the records from before and after it. Medrecords AI can only cite what you give it. The parts that matter most, such as nursing notes, flowsheets and timed lab results, are also the parts most often left out of a production.
Help center contents26 articles
Start here
Work with the records
Write and share
Account and trust
Case type playbooks
Start with the core of the chart
These records tell the story of the care. Upload all of them for the stay or visit at issue.
- Emergency room notes and triage notes
- Doctors' orders, with the times they were written
- Progress notes from doctors and nurses
- Nursing notes and nursing flowsheets
- The medication record, often called the MAR. It shows each dose given and when
- Lab results, with the time drawn and the time reported
- Imaging reports
- Consult notes
- Surgery and anesthesia records, if there was a surgery
- The discharge summary and discharge instructions
Add the records around the event
The care at issue is only part of the story. Your expert will want to see what came before and after.
- Records from before the event, to show how the patient was doing
- Follow-up visits and later hospital stays
- Outside records, such as a clinic that saw the patient the week before
- Pharmacy records
- Bills, if damages matter to the case
Parts that are often left out
Hospitals often send a short version of the chart. Look for these gaps when records come in.
| Often missing | Why it matters |
|---|---|
| Nursing flowsheets | They hold vital signs and checks, often hour by hour |
| The MAR | It shows whether an ordered drug was given, and when |
| Timed lab reports | A result with no time makes it hard to trace the response |
| Phone and message notes | They can show whether a result was passed on |
| Late entries and add-on notes | Notes added later can change the picture |
| Fetal monitor strips, for a birth injury | They are often sent apart from the chart |
After you upload, the missing records list shows records that other records mention but the file does not hold.
Request the audit trail on its own
Medrecords AI does not read EHR audit trails or metadata. An audit trail is the system log of who opened or changed the chart, and when. Request it from the provider as a separate item, and have it reviewed apart from the app. Our guide on EHR audit trails in medical malpractice explains what to ask for.
File types the app reads
- PDF, images, Word and text files are read.
- ZIP files unpack in your browser.
- TIFF, GIF and HEIC files are not read. Save them as PDF or JPG first.
- DICOM imaging files are stored and you can view them, but the app does not read them. Upload the written imaging report too.
See file types and limits for the full list. If more records arrive later, add them to the case. Duplicate pages are removed for you.
Upload tips
- Upload the whole production, not just the pages you think matter.
- Keep each provider's records together where you can.
- Check that scans are clear. Faint pages and handwriting are where mistakes are most likely.
Medrecords AI organizes and cites the records. Its output is not a medical or legal opinion and does not replace your expert.
Related help
- Review a medical malpractice case in Medrecords AI
- Find med mal records that are referenced but not produced
- Add records to an existing case
- File types and limits
Facts checked against the Medrecords AI app code on 2026-10-24.