Includes bibliographical references and index.

What is the medical chart -- Acquiring the medical record / Karen Fielder -- Authorization for Release of medical information -- Determining what is missing from the medical chart -- How to examine the medical chart -- Face sheet -- Consent forms -- Living will/Power of attorney -- Pre-admission records -- Ambulance call report -- Emergency department record -- Admission note -- Physician order sheet -- Progress note -- Consultation note -- Anesthesia note -- Procedure note -- Discharge summary -- Radiology report -- Laboratory and pathology reports -- Autopsy report -- Nursing notes -- Medical policies -- Incident reports -- Medication errors / Kim Zammit -- The medical chart as evidence / Edward Birnbaum and Carl Grasso -- Tampering or falsification? -- Malpractice basics -- Pain and suffering -- Personal injury claims.