A Complete Medical Chronology Sample, Cited to the Record
Prepared by a licensed U.S. attorney
A medical chronology example shows how a treatment history is laid out for litigation: every medically significant event in date order, each with a citation to the record pages behind it. This one covers a 412-page file from a rear-end collision, from the emergency room through maximum medical improvement.
It is the whole deliverable, not an excerpt, published here with no form. The matter is an illustrative composite. It is not a real patient, client, or claim.
By the Legal Tank editorial team
What a medical chronology should contain
Four parts, in the order below. A date list stops at the second one.
Records reviewed
Every provider, Bates range and page count, so a reader can see the set is complete before trusting a single entry.
Dated entries
Date, provider, what happened, and the exact pages. Gaps in care get their own row instead of disappearing between visits.
Billing reconciliation
Charges by provider and service window, with the duplicate check stated, so the specials total holds up.
Flags and missing records
The facts that cut against the claim, plus what the file refers to but does not contain, for counsel to act on first.
Sample deliverable
Delgado v. Kestrel Freight Lines, Inc., et al. (pre-suit)
- Claimant
- Maria E. Delgado (DOB 04/12/1983)
- Date of loss
- 03/14/2025, rear-end MVC, Dallas County, Texas
- Limitations
- Two years, Tex. Civ. Prac. & Rem. Code § 16.003; expires on or about 03/14/2027 (verify tolling and notice issues).
Records reviewed
| Provider | Bates range | Pages |
|---|---|---|
| Mercy General Hospital (ER) | MG 001-078 | 78 |
| Radiology Associates of Dallas | RAD 001-034 | 34 |
| Reyes Family Medicine (PCP) | REY 001-052 | 52 |
| Lakeside Physical Therapy | LPT 001-141 | 141 |
| North Texas Pain & Spine | NTPS 001-066 | 66 |
| Metroplex Orthopedic Group | MOG 001-041 | 41 |
| Total | 412 | |
Provider prefix plus page within that production (for example, MOG 017). All entries cite the paginated set as produced.
Chronology of medically significant events
| Date | Provider | Event | Cite |
|---|---|---|---|
| 03/14/2025 | Mercy General ER | Arrival by EMS ~14:37 after rear-end impact by commercial box truck, restrained driver, airbags did not deploy. GCS 15. Chief complaint: posterior neck pain 7/10, occipital headache, left trapezius tenderness. Dx: cervical strain (S16.1XXA). Discharged with naproxen 500 mg BID and cyclobenzaprine 5 mg HS; head injury precautions given. | MG 004-011 |
| 03/14/2025 | Mercy General ER (imaging) | CT cervical spine without contrast: no acute fracture, subluxation, or prevertebral soft tissue swelling. | MG 041-044 |
| 03/18/2025 | Reyes Family Medicine | PCP follow-up. Persistent cervicalgia radiating to left shoulder; cervical flexion limited to ~30 degrees (normal ~50); Spurling negative. Plan: continue NSAIDs; referral to physical therapy 2x/week for 6 weeks. | REY 006-009 |
| 03/24/2025 | Lakeside Physical Therapy | Initial PT evaluation. Neck Disability Index 42% (moderate to severe). Pain 6/10. Plan of care: 12 visits, manual therapy plus therapeutic exercise. | LPT 001-006 |
| 04/15/2025 | Lakeside Physical Therapy | Progress note at 8 visits. Pain 5/10, NDI 36%. Patient reports intermittent paresthesias in left C6 distribution (thumb/index finger); therapist recommends physician re-evaluation if radicular symptoms persist. | LPT 034-037 |
| 05/12/2025 | Reyes Family Medicine | Re-evaluation. Radicular symptoms persisting beyond 8 weeks despite conservative care. MRI cervical spine ordered. | REY 014-016 |
| 05/27/2025 | Radiology Associates | MRI cervical spine: 3 mm left posterolateral disc protrusion at C5-6 abutting the thecal sac with mild ventral effacement; no cord compression or myelomalacia. Mild multilevel degenerative changes noted. (15-day order-to-study interval; insurer authorization delay documented at REY 018.) | RAD 017-021 |
| 06/09/2025 | Metroplex Orthopedic Group | Orthopedic spine consult. Exam consistent with left C6 radiculopathy; correlates with MRI. Opinion: findings causally related to the 03/14/2025 collision within reasonable medical probability, superimposed on previously asymptomatic degenerative changes. Recommends transforaminal ESI series and continued PT. | MOG 008-017 |
| 06/24/2025 | North Texas Pain & Spine | Left C5-6 transforaminal epidural steroid injection #1 under fluoroscopic guidance; no complications. Approximately 60% relief for ~3 weeks reported at follow-up. | NTPS 012-019 |
| 07/08/2025 - 07/26/2025 | No treatment (18 days) | Documented out-of-state family travel; PT attendance note reflects planned absence. Benign explanation appears in the record itself. | LPT 088 |
| 08/05/2025 | North Texas Pain & Spine | Left C5-6 transforaminal ESI #2. Partial relief (~40%), shorter duration than ESI #1. | NTPS 033-041 |
| 08/28/2025 | Lakeside Physical Therapy | Re-evaluation at 24 total visits. NDI 28%. Functional plateau documented; transition to home exercise program recommended. | LPT 118-123 |
| 09/16/2025 | Metroplex Orthopedic Group | Follow-up. Symptom plateau. Surgical options discussed (ACDF as future contingency); patient elects continued conservative management. Permanent activity modification: no overhead lifting over 10 lbs. | MOG 024-029 |
| 10/07/2025 | Reyes Family Medicine | Work status note: 19 full and 11 partial shifts missed from warehouse lead position since DOL; employer wage verification requested (outstanding, see the missing records list). | REY 037-039 |
| 11/20/2025 | Metroplex Orthopedic Group | Maximum medical improvement declared. Residual chronic cervicalgia with intermittent left C6 radicular symptoms. Future care: episodic PT for flares; possible repeat ESI once to twice yearly. | MOG 033-038 |
Billing reconciliation (billed charges as produced)
| Provider | Service window | Billed |
|---|---|---|
| Mercy General Hospital (ER, incl. CT) | 03/14/2025 | $8,412.50 |
| Radiology Associates (MRI C-spine) | 05/27/2025 | $2,850.00 |
| Reyes Family Medicine (4 visits @ $160) | 03/18/2025 - 10/07/2025 | $640.00 |
| Lakeside Physical Therapy (24 visits @ $185) | 03/24/2025 - 08/28/2025 | $4,440.00 |
| North Texas Pain & Spine (2 ESI @ $3,975 + eval $425) | 06/24/2025 - 08/05/2025 | $8,375.00 |
| Metroplex Orthopedic Group (consult $395, 2 f/u @ $295, MMI report $600) | 06/09/2025 - 11/20/2025 | $1,585.00 |
| Total billed specials to date | $26,302.50 | |
Billed charges only; paid and adjusted amounts and lien ledgers not yet produced. Duplicates checked across MG facility and RAD professional billing; none found.
Flags for counsel
- Prior cervical complaint. 06/2019 cervical strain after a gym incident, resolved with 4 PT visits by 10/2019, no imaging performed (REY 044-046). Recommend addressing it in the demand rather than leaving it for the adjuster to find.
- Degenerative findings. The 05/27/2025 MRI notes mild multilevel degenerative changes (RAD 019). Expect an age-related-degeneration defense; the treating orthopedist’s causation opinion (MOG 017) expressly addresses aggravation of previously asymptomatic degeneration and should anchor the causation section.
- Treatment gap 07/08-07/26/2025 (18 days). Documented family travel (LPT 088). Benign and explained inside the record; cite the attendance note affirmatively if the gap is raised.
- Authorization delay. 15 days from MRI order to study (REY 018). Attributable to insurer authorization, not patient noncompliance.
- Damages exposure is understated. Pharmacy dispensing records and employer wage verification are not yet in the set; current specials reflect billed charges only.
Missing records list
- Pharmacy dispensing records (naproxen, cyclobenzaprine, gabapentin trial referenced at MOG 026): not yet produced.
- Employer wage verification for 19 full and 11 partial missed shifts (requested 10/07/2025, REY 038).
- 2019 PT records for the prior cervical strain (4 visits): obtain to bound the prior-injury defense.
- Health insurance lien and subrogation ledger: request before the demand issues.
Prepared for reviewing counsel as litigation support work product. Every entry is verifiable against the cited pages; no clinical conclusions are offered beyond those stated by the treating providers.
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How to read this medical chronology
Start with the 18-day gap in July. A date list would show nothing there, and an adjuster would call it a break in care. This sample gives the gap its own row and cites the PT attendance note that explains it, so counsel can answer the point before it is raised.
Then read the MRI entry against the flags. The degenerative language at RAD 019 is the defense's best fact, and the treating orthopedist's opinion at MOG 017 is the answer to it. Putting both in front of counsel, with the pages, is what the document is for.
Need this for a real file?
A licensed U.S. attorney prepares each chronology from your record set, in this format, for a flat quote set after we read the records. To build one yourself, start with the medical chronology builder.
See medical chronology servicesLegal Tank is not a law firm. Sample for illustration only; not legal advice.