# Sample Medical Chronology: Post-Op Infection

> A sample medical chronology shown in full: 23 dated entries from a post-op spinal fusion infection, each cited to its source page, with 4 review flags.

Canonical page: https://medrecords.ai/sample-medical-chronology/

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## Sample medical chronology: a post-op infection, entry by entry

Sample medical chronology for a post-op infection: 1 fictional patient, followed from a lumbar fusion on 08/12/2024 through a deep wound infection, septic shock and a revision surgery. Every entry below comes from the Medrecords AI PDF and cites its source page, so a physician reviewer or risk manager can check any line against the record.

By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/), Co-Founder & CEO of Medrecords AI · Published 3 Nov 2026

### What does a medical chronology look like?

A medical chronology is a table with 1 row per encounter, in date order: the date, the provider or facility, what happened, and the page it came from. Rows that need a reviewer's attention carry a flag, so alerts and gaps sit in the timeline where they happened.

The table holds 23 of the PDF's 24 entries. We left out the 24th, a May 2026 IME, because it is an opinion about this record rather than care in it. It is in the [full PDF](https://medrecords.ai/assets/samples/pdf/medical-chronology/medical-malpractice-sample.pdf).

| Date | Provider / facility | Event and findings | Source | Flag |
| --- | --- | --- | --- | --- |
| 07/30/2024 | Lakeside Spine & Ortho, Dr. C. Harmon | Pre-op visit. 63-year-old with L4-L5 degenerative spondylolisthesis and neurogenic claudication. Surgery scheduled; medical clearance obtained. | p. 8 | None |
| 08/12/2024 | Lakeside Surgical Center | Admission and procedure. L4-L5 decompression and posterolateral fusion with instrumentation. Estimated blood loss 350 mL; operative time 3h 40m. | p. 24 | None |
| 08/12/2024 | PACU | PACU. Stable; vital signs WNL; pain controlled; neuro exam intact. | p. 31 | None |
| 08/13/2024 | Lakeside Surgical Center | POD 1. Tmax 38.2 C (100.8 F); incision clean, dry, intact; WBC 12.1; IV antibiotics (cefazolin) continued. | p. 38 | None |
| 08/14/2024 | Lakeside Surgical Center | POD 2, fever. Tmax 38.8 C (101.8 F); WBC 14.8; HR 108; nursing note flags fever and malaise; discharge planned despite fever per order set. | p. 44 | Alert |
| 08/14/2024 | Lakeside Surgical Center | Discharge. Discharged home POD 2. Discharge note documents "low-grade fever, presumed atelectasis"; no blood cultures drawn; no wound cultures; no imaging. | p. 48 | Alert |
| 08/15/2024 | Home | Post-discharge day 1. Patient called clinic reporting chills and incisional drainage; advised to monitor, offered an appointment in 5 days. | p. 55 | Alert |
| 08/17/2024 | Lakeside Medical Center, ED | ED readmission. Tmax 39.4 C (102.9 F); HR 122; BP 92/58; incision erythematous with purulent drainage; lactate 3.8; sepsis protocol initiated; admitted. | p. 63 | None |
| 08/18/2024 | ICU | ICU admission. Septic shock; vasopressors; blood cultures x2; wound cultures; empiric vancomycin plus piperacillin/tazobactam. | p. 74 | None |
| 08/20/2024 | OR, Dr. C. Harmon; ID consult | Surgical debridement. Deep wound infection; 400 mL purulent collection; extensive debridement; instrumentation retained; wound vac placed. | p. 89 | None |
| 08/21/2024 | ICU, ID | ID follow-up. Cultures: methicillin-sensitive S. aureus. Narrowed to cefazolin 2 g q8h; 6-week course planned. | p. 96 | None |
| 09/02/2024 | Medical unit | Step-down. Improved; wound vac changes; ambulation with assistance; glucose control. | p. 105 | None |
| 09/18/2024 | Lakeside Medical Center | Discharge. Discharged to home health on IV antibiotics; wound vac in place; PICC line. | p. 117 | None |
| 10/14/2024 | Wound clinic | Wound follow-up. Wound granulating; vac removed; wet-to-dry dressings; cultures negative. | p. 128 | None |
| 11/12/2024 | Ortho follow-up, Dr. C. Harmon | Post-op follow-up. X-rays: hardware intact, no loosening. Persistent back and left leg pain; referred to pain management. | p. 136 | None |
| 01/09/2025 | Lakeside Medical Center | CT lumbar. Mild lucency at left L5 pedicle screw; question of early loosening. MRI with contrast shows residual epidural enhancement. | p. 147 | Gap |
| 04/03/2025 | Second opinion, Dr. E. Vance | Orthopedic second opinion. Nonunion of L4-L5 with hardware loosening; chronic pain; revision discussed. | p. 158 | None |
| 04/22/2025 | OR, Dr. E. Vance | Revision surgery. L4-L5 revision with explant of loose hardware, decompression, autograft plus BMP, new instrumentation. | p. 172 | None |
| 06/10/2025 | Post-op follow-up, Dr. E. Vance | Follow-up. Healing progressing; left leg pain improved 50%; gait stable. | p. 184 | None |
| 09/08/2025 | Pain management | Pain consult. Chronic post-operative pain; gabapentin, PT, cognitive-behavioral referral. | p. 196 | None |
| 12/12/2025 | Ortho follow-up, Dr. E. Vance | Follow-up. X-rays show consolidation; range of motion limited; permanent restriction: no lifting over 15 lb. | p. 205 | None |
| 03/11/2026 | Lakeside Medical Center | MRI lumbar. No recurrent infection; hardware intact; mild epidural fibrosis at L4-L5. | p. 214 | None |
| 07/01/2026 | Ortho follow-up, Dr. E. Vance | Final treating note. MMI reached; maintenance gabapentin; annual follow-up; future care plan documented. | p. 231 | None |

**About this sample.** The case is fictional and de-identified. Source pages refer to the page numbers of the demo packet, as printed in the PDF.

### Where a standard-of-care review starts

The 3 alerts fall on 08/14 and 08/15/2024, between a fever on post-op day 2 and the ED readmission on 08/17. A reviewer has to answer 3 questions from those pages:

- Was discharge per the order set reasonable with a Tmax of 38.8 C, a WBC of 14.8 and a heart rate of 108 (p. 44)?
- Why does the discharge note attribute the fever to presumed atelectasis with no blood cultures, wound cultures or imaging (p. 48)?
- Did an appointment 5 days out fit a call reporting chills and incisional drainage the day after discharge (p. 55)?

The gap flag on 01/09/2025 is a different kind of item. The CT raises early screw loosening and residual epidural enhancement nearly 3 months before the second opinion found nonunion (p. 147, p. 158). The chronology does not say what that means. It puts the page in front of the reviewer.

Medrecords AI drafts and cites. The physician or reviewer reviews and signs. A flag is a prompt for that review, never a finding.

### Get the full file and the template

**Full PDF, 4 pages** The same chronology with the case overview, encounter times and all 24 entries. [Download the PDF](https://medrecords.ai/assets/samples/pdf/medical-chronology/medical-malpractice-sample.pdf).
**The sample page** The post-op infection chronology in the samples library, with a page 1 preview. [Open the post-op infection sample](https://medrecords.ai/content-hub/samples/post-op-infection-med-mal-chronology-sample/).
**A blank template** The same columns in a spreadsheet you fill in by hand, with a filled example from this case. [Use the chronology template](https://medrecords.ai/content-hub/samples/medical-chronology-template/).
For the product view, see [medical chronology software](https://medrecords.ai/product/chronology/) and how [every line links to its source page](https://medrecords.ai/product/citations/). For hospital and physician review work, see [medical malpractice record review](https://medrecords.ai/solutions/medical-malpractice/).

### Sample medical chronology FAQs

**What is a medical chronology used for in standard-of-care review?** It gives the reviewer the sequence of care with a page behind every entry, so the question of what was known, when, and by whom gets answered from the record. In this sample that sequence is a fever on post-op day 2, discharge the same day, and readmission with sepsis 3 days later.
**What do the Alert and Gap flags mean?** Alert marks an entry to read first, such as a discharge with a documented fever and no cultures. Gap marks something the record raises but does not resolve, such as the 01/09/2025 CT that questions early screw loosening. A flag is a prompt for review, not a conclusion.
**How is each entry cited?** Each row carries the page of the source packet it came from, for example p. 48 for the discharge note. In Medrecords AI each citation opens that source page, so you check the entry against the original instead of trusting the summary.
**Is this a real patient?** No. The case is fictional and de-identified. The names, facilities and case number in the PDF belong to a demo case built to show the format.
**How long does Medrecords AI take to build a chronology like this?** It reads about 100 pages a minute, so a packet the size of this one, cited up to p. 231, is read in a few minutes. Your review of the draft takes longer, and it should.
**What does it cost?** Pricing starts at 10 cents per deduplicated page, down to 5 cents with volume. Exact duplicates are never charged, there is no subscription, and credits never expire. First case is free on us.

### See your own record as a chronology

Bring 1 real case to a demo. Access opens within 1 business day after it, and you review and sign everything the software drafts. First case is free on us.

[Book a demo](https://medrecords.ai/demo/)