Glossary: med mal review and AI terms

By Ahmed Jemaa, Co-Founder and CEO of Medrecords AI. Updated 2026-11-12.

Limits: We read each product's own web pages on 2026-11-12 and did not upload records to any of them, ours included. Prices, plans and features change, and nothing here is legal advice or a substitute for your own clinical judgment.

Legal terms a reviewer meets

Standard of care

What a reasonably careful physician in the same specialty would have done in the same circumstances, judged as of the date of care. The exact wording differs by state; ask the retaining attorney for the one that applies.

Deviation (departure)

Care that fell below the standard of care. On this site, a "candidate deviation" is a fact pattern worth a look, such as a long gap between a result and a response, before any judgment is made.

But-for causation

The test that asks whether the harm would have happened anyway without the breach. If it would have, the breach was not its cause in fact.

Proximate cause

An actual cause that is also legally enough to support liability, often tested by whether the harm was foreseeable.

Loss of chance

A theory under which a patient claims a reduced chance of a better outcome, even when the outcome itself may not have changed. Whether and how it applies depends on the state.

Reasonable medical probability

The degree of confidence many courts ask an expert to state an opinion to, often read as more likely than not. Some jurisdictions say "reasonable medical certainty" and mean much the same thing.

Affidavit or certificate of merit

A statement from a qualified expert, required in some states early in a med mal case, that the claim has a reasonable basis. Often the first written work a physician reviewer is asked for.

Charting terms that change a timeline

Late entry

A note written after the time it describes and marked as such. In a timeline it carries 2 dates: the event and the writing.

EHR audit trail

The system log of who opened, created or changed what in the electronic record, and when. It can show when a result was first viewed or a note was edited. It is rarely in the produced chart.

MAR (medication administration record)

The record of each dose given, held or missed, often with barcode scan times. It frequently arrives as a scanned grid.

Flowsheet

The tabular part of the chart for vitals, intake and output, neuro checks and other repeated measures. Often holds both the time a value was taken and the time it was filed.

Copy-forward

Text carried from an earlier note into a new one. A copied exam can read like a fresh exam to a person or to an AI tool.

Outcome bias (hindsight bias)

The tendency to judge care more harshly when the outcome was bad. A 1991 JAMA study measured it among anesthesiologists reviewing matched cases.

Bates number

The unique stamp on each produced page. The surest way to cite a page in a report.

AI and privacy terms

Page citation

A link or reference from each line of AI output to the page of the record it came from. A citation to a journal article is a different thing and does not count here.

Chronology

A dated list of events from the record. A standard-of-care timeline is a narrow, minute-level chronology of the critical window.

Deduplication

Removing exact repeat pages before review or billing. Productions from several sources often hold the same pages more than once.

Hallucination

AI output that is fluent and wrong, such as an event that never happened or a paper that does not exist.

BAA (business associate agreement)

The HIPAA contract between a covered entity or business associate and a vendor that handles PHI for it. Check that it names the product and plan you actually use.

PHI (protected health information)

Health information that identifies a person. Chart pages, names, dates of service and record numbers all count.

DICOM

The standard file format for medical images. Reviewing the study itself, not only the radiology report, needs the DICOM files.