Medical records and documents: Frequently asked questions

You can start with the pathology report, imaging, and treatment records you already have. Provide the complete pathology report whenever possible. It should show the diagnosis, specimen site, test date, immunohistochemistry, and molecular or genetic results.

A hospital may request pathology slides, paraffin blocks, or digital pathology files for diagnostic review. First confirm which institution holds them. Ask whether its process allows release, transfer, or digitization. Do not send pathology materials before the receiving hospital gives clear instructions.

Prepare the diagnosis or case summary you already have. Include recent reports and original imaging or access details. Add pathology materials, treatment history, current medications, and allergies. A hospital may request your passport identity page for real-name registration.

State the question you need the hospital to assess. This may include remote assessment, the right specialty, an in-person visit, or missing records. Requirements vary by hospital and specialty. We will check the requested materials and submission method first.

Start with a one-page case summary. Include the main diagnosis or symptoms. List important tests, dates, previous treatment, and treatment response. Add current medications, allergies, underlying conditions, and questions for the doctor.

Arrange reports in chronological order and keep the originals. Prioritize recent records that directly relate to the current question. If there are many files, submit the summary and latest reports first. Add key history and further documents when the hospital requests them. Do not alter reports or send screenshots that omit the date, hospital, or conclusion.

An imaging report records the radiologist's written conclusion. Original DICOM files contain the full image data from CT, MRI, PET-CT, and similar studies. Doctors may need the images to assess location, extent, or changes over time.

You can still begin an inquiry with the report alone. Explain where the original images are stored. They may be on a disc, patient portal, QR code, or download link. The hospital considers the condition, image date, and quality. It then decides whether DICOM files or new testing are needed. Do not repeat scans on your own.

Whether translation is needed depends on the receiving hospital, specialty, and original language. Chinese or English originals are usually easier to process. Reports in other languages may require a Chinese or English translation.

Prioritize decision-critical materials. These include the case summary, diagnosis, pathology reports, and recent imaging reports. They also include treatment records, medication lists, allergies, and discharge summaries. Keep original files with their translations. If there are many records, submit an index, summary, and core documents first. Translate further materials only when the hospital requests them.