Preparing records for a centre in another country

A foreign centre can only judge what you send them.

An incomplete package produces a cautious, generic reply that helps nobody.

What to include

• A one-page summary written by you, dated.
• Referral or summary letter from your specialist.
• All laboratory results in chronological order.
• Imaging studies in original digital format.
• Written radiology reports for each study.
• Pathology reports in full, not only the conclusion.
• Operation notes if you have had surgery.
• A current medicine list with generic names.

The one-page summary

• Age, sex, height and weight.
• Diagnosis in full, with date and who made it.
• How the illness began and how it has progressed.
• Treatments given, with dates and response.
• Other medical conditions.
• Allergies and previous adverse reactions.
• Current status and what you can no longer do.
• Your three main questions at the end.

Imaging done properly

• Request the original digital study, not a printed film.
• Ask the receiving centre which format they accept.
• Check the files open before sending.
• Include earlier studies so change over time is visible.
• Label each study clearly with its date.
• Sequence over time is often more informative than one image.

Pathology

• Send the full report, including the description sections.
• Ask whether the centre wishes to review the slides themselves.
• Ask your original laboratory about lending the material.
• Ask how and when it will be returned.
• Independent review sometimes changes the diagnosis entirely.

Requesting your records

• Ask which department handles requests.
• Ask what identification is needed.
• Ask about fees and turnaround time.
• Request two complete copies from the start.
• Check the package for completeness before you leave.
• Access to your own records is a normal right, not a favour.

Organising the package

• Put the summary first.
• Order everything else by date.
• Name files so they sort chronologically.
• Group by type: laboratory, imaging, pathology, operative.
• Add a one-page index.
• A tidy package receives more careful attention.

Translation

• Ask the centre what must be translated before paying for anything.
• Usually the summary and principal reports are enough.
• Use a translator with medical experience.
• Keep generic drug names untranslated.
• Keep laboratory units exactly as printed.
• Never convert numbers yourself.
• Always send the original alongside the translation.

Checking the translation

• Verify your name matches your passport exactly.
• Verify dates have not been reordered.
• Verify numbers and units are unchanged.
• Ask your own clinician to glance over it if possible.
• Errors found now are far cheaper than errors found later.

Include what has already been ruled out

• Negative results are informative, not filler.
• List diagnoses already excluded and how.
• List treatments tried and why they were stopped.
• This prevents the receiving team repeating work.
• It also prevents them proposing something already attempted.

Include functional information

• What you can and cannot do in daily life.
• Whether you work, and in what role.
• How far you can walk and what limits you.
• Weight change over recent months.
• This context shapes what treatment is realistic.

Write your questions clearly

• Is the current diagnosis correct?
• Is the current treatment plan appropriate?
• What would you propose instead, and why?
• Do I need to travel, or can this be done at home?
• What would you need in addition to answer more fully?
• Precise questions produce usable answers.

Sending securely

• Use the centre's official channel only.
• Do not post records in public groups.
• Do not send to an individual's personal account.
• Ask how your data will be stored and for how long.
• Keep the originals and send copies.

Ask what standard is used to report results

• Reference ranges differ between laboratories.
• Always send the printed range alongside each value.
• Note which laboratory performed each test.
• This avoids misinterpretation abroad.

Tracking the request

• Record what you sent, when, and to whom.
• Obtain written confirmation of receipt.
• Note the promised response date.
• Follow up politely if it passes.
• Keep the whole exchange in one place.

File size and delivery

• Imaging files are large; ask how the centre prefers to receive them.
• Some accept secure upload portals.
• Some prefer physical media sent by courier.
• Confirm they opened everything successfully.
• Do not assume silence means receipt.

Common mistakes

• Sending only the most recent results.
• Sending photographs of screens instead of digital studies.
• Omitting the pathology report.
• Omitting dates.
• Failing to state the questions.
• Sending files too large to open.
• Each of these delays the answer by weeks.

Consent and data use

• Ask what you are consenting to when you send records.
• Ask whether data may be used for research or teaching.
• Ask how long records are retained.
• Ask how to request deletion afterwards.
• Read the consent text rather than ticking it.

Ask what format the reply will take

• A written report is more useful than a phone call.
• Ask whether you may seek clarification afterwards.
• Ask how long the opinion remains valid.

Keep the package for reuse

• Store the organised digital set safely.
• Update it after every new investigation.
• Reuse it for any further opinion.
• Make sure one family member knows where it is.
• Building it once saves repeating the work.

The point to remember

Three things:

1. Your own dated one-page summary is the single most valuable document.
2. Send original digital imaging with earlier studies, not photographs of films.
3. Confirm what must be translated before paying to translate anything.

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