RESOURCE
How to prepare medical records.
Clear care program records help hospitals understand the case and reduce back-and-forth before review.
Start with a one-page summary
Include diagnosis, main concern, current symptoms, important dates, prior treatment, medications, allergies, and what you want to understand.
Collect core documents
- Diagnosis summaries and physician letters.
- Lab results and imaging reports.
- Pathology reports when relevant.
- Medication list, allergies, and medical history.
- Procedure notes and discharge summaries.
Keep imaging usable
When possible, keep original imaging files in a format the receiving hospital can review, especially for second opinion or orthopedic planning. A written report alone may not be enough for some specialties.
Protect privacy
Share only what is needed for the next coordination step. Ask who will receive records and why before sending sensitive documents.
Disclaimer
This guide is educational. Medical interpretation belongs to licensed clinicians.