Chart summary glossary

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

Limits: Vendor facts come from each vendor's own website on 2026-11-12 and were not tested by us. Rules are summarized from the cited text; your hospital's bylaws, payer contracts and state law can ask for more.

Summary types

Pre-visit summary

A short summary prepared before a visit: what changed since the last visit, results to review and care gaps due. A workflow tool with no federal content rule.

Consult summary

The consultant's note back to the requesting physician: the question, the answer and specific recommendations. Sent electronically as a C-CDA Consultation Note (LOINC 11488-4).

Transfer summary

The summary that travels with a patient to another unit or hospital. Sent electronically as a C-CDA Transfer Summary (LOINC 18761-7).

Discharge summary

The hospital's summary of a stay for the clinicians who take over. CMS requires one with the outcome of hospitalization, disposition and follow-up care (42 CFR 482.24(c)(4)(vii)). LOINC 18842-5.

Problem list

The running list of a patient's problems, each with status. It comes from Lawrence Weed's problem-oriented medical record (NEJM, 1968). LOINC 11450-4 for a reported problem list.

Continuity of Care Document (CCD)

A C-CDA document type holding a core data set (allergies, medications, problems, results and more) for sharing a patient's current state. LOINC 34133-9, "Summary of episode note".

Fields and content

Hospital course

The part of a discharge summary that tells what happened during the stay. Best written by problem, not by day. LOINC 8648-8.

Disposition

Where the patient went at discharge: home, home with home health, a skilled nursing facility, another hospital, hospice. Required in the discharge summary by 42 CFR 482.24.

Pending results

Tests ordered before a transition whose results come back after it. Roy and colleagues found 41% of discharged patients had results pending (Ann Intern Med, 2005). Each needs a named person who will act on it.

Medication reconciliation

Comparing the medications a patient takes with the ones newly ordered, and resolving each difference. In a summary it shows as a list where every drug is marked new, changed, held, restarted, stopped or unchanged.

Incidental finding

A finding unrelated to the reason a test was done, such as a lung nodule on a CT ordered for a pulmonary embolism. It needs its own line and an owner, because it isn't on the problem list yet.

Pertinent negative

A finding that is absent and matters, such as "no pulmonary embolism on CT". Losing the "no" turns a negative into a positive.

Code status

The patient's documented choice about resuscitation, such as full code or do not resuscitate. Transfer and discharge summaries should state it with the date it was confirmed.

Goals of care

What the patient wants care to achieve. 42 CFR 482.43(b) names post-discharge goals of care and treatment preferences among the information sent at discharge or transfer.

Consult question

The specific question the requesting physician wants answered. Goldman, Lee and Rudd's 1983 consultation rules start by pinning it down.

Standards and rules

C-CDA

HL7 Consolidated Clinical Document Architecture: the standard US EHRs use to send clinical documents to each other. Version 5.0.0 defines document templates such as the Discharge Summary, Transfer Summary, Consultation Note and Referral Note, and marks which sections each requires.

LOINC

Logical Observation Identifiers Names and Codes: the code system that labels tests and document types. A discharge summary sent between systems carries LOINC 18842-5.

EMTALA

The Emergency Medical Treatment and Labor Act. Its rule at 42 CFR 489.24(e)(2)(iii) lists the records a hospital must send with a patient it transfers from the emergency department.

Conditions of Participation

The CMS rules hospitals must meet to take part in Medicare, in 42 CFR part 482. Section 482.24 covers medical records; 482.43 covers discharge planning and transfers.

Handoff

The transfer of responsibility for a patient from 1 clinician or team to another, in speech, writing or both. A transfer summary is a written handoff.

I-PASS

A structured handoff program built around a mnemonic for oral and written handoffs. In a 9-hospital study, medical errors fell 23% and preventable adverse events fell 30% after it was introduced (Starmer et al., NEJM 2014).

Pre-visit planning

Preparing for a visit ahead of time. AMA team-care guidance suggests doing it 2 to 3 days before the visit: review the last notes, check for care gaps, and find outside records.

Confabulation

A statement in an AI-drafted summary that the chart doesn't support. The 2025 NYU Langone study of AI hospital course drafts used the term (Small et al., JAMA Netw Open 2025).