How to prepare medical records for a digital service

Start with the question

For a new symptom, the clinician needs its onset and progression, associated symptoms, medicines, relevant conditions and targeted investigations. A strategic oncology review or trial search needs a coherent disease timeline and the primary reports that support it.

Ask the recipient what is required, who can access it, how long it will be retained and whether a protected portal is available. Avoid sending a complete archive when most pages do not answer the question.

Build a short clinical timeline

Discharge summaries and a current outpatient summary are useful starting points because they connect diagnoses, admissions, procedures, systemic treatment, radiotherapy, complications and follow-up. Attach full pathology, molecular or imaging reports separately when the summary only mentions them.

Record dates, events, treatments and outcomes without rewriting the clinician's diagnosis. Include full drug names and, when available, start and stop dates, dose and reason for change.

1. Diagnosis and evidenceUse the wording in the report and identify the document that supports it.
2. Key investigationsList pathology, molecular testing and studies used for staging or response assessment.
3. TreatmentProcedures, systemic regimens, radiotherapy, response, toxicity and reason for change.
4. Current statusRecent summary, symptoms, medicines, allergies and clinically important conditions.

Oncology records that commonly matter

The final pathology report is a primary source for tumour type. Preserve the specimen source, site, histologic type, grade and immunohistochemistry when performed. If there was a repeat biopsy or expert review, include the relevant reports and make the sequence clear.

Staging may draw on CT, MRI, PET/CT, endoscopy, operative notes and pathology. Send the radiology reports and, only when requested, the DICOM images through an agreed route. A screen photograph is not a substitute for the original study.

Share a complete molecular report: specimen, method, genes or biomarkers tested, detected and negative findings, technical limitations and date. An isolated result without method and context may not be interpretable.

• final pathology or cytology and relevant immunohistochemistry
• complete molecular and biomarker reports
• imaging reports at diagnosis, before major treatment changes and at the latest assessment
• operative notes and hospital discharge summaries
• sequence of anticancer treatments and documented response
• current medicines, allergies, organ function and important comorbidities

Record the diagnosis date—do not invent it

The diagnosis date is often linked to microscopic confirmation in a pathology report, but a malignancy may sometimes be clinically documented earlier or without tissue. Use the date and wording recorded by the medical team.

Keep first symptom, first visit, imaging, specimen collection, final report and treatment start as separate dates when relevant.

Laboratory tests depend on the purpose

A recent blood count, renal and liver function and other tests may matter for current safety or trial screening. Their usefulness depends on the clinical question and how recent they are.

A urinalysis can be important for a specific symptom, condition or protocol, but it does not replace pathology, molecular evidence or response imaging in a strategic oncology review. Prioritise by question, not by the size of a routine panel.

Prepare a separate copy with fewer direct identifiers

Keep originals. When identity is not needed for preliminary review, remove full name, exact birth date, address, telephone, email, passport and insurance numbers, record numbers, barcodes, QR codes, signatures and third-party contacts. Age, sex and clinical dates may remain clinically relevant, so clarify how the recipient wants them represented.

A black rectangle in a PDF may only cover visible text. Save a final copy and verify that hidden content cannot be selected, searched, copied or exposed in file properties. Remove irrelevant pages and personal data from file names.

Use the minimum necessary data and an agreed channel

Verify the recipient, transfer route, retention period and deletion options. Do not use a public link or a general chat merely because the recipient is personally known. Consent is an important governance step, but it is not a security control.

Poltoratsky.rf does not accept medical-document uploads. MIKA.help, email, messaging and other external services have their own operator, privacy and consent terms; review those terms before sharing.