Medical records

What to prepare for a meaningful specialist review

Complete records reduce unnecessary delay and help clinical teams understand what has already been established.

Do not send original medical material unless a receiving institution has confirmed how it should be delivered.

Essential medical information

  • Full name as shown on passport
  • Date of birth
  • Country of residence
  • Current diagnosis
  • Date of diagnosis
  • Relevant medical conditions
  • Previous cancers
  • Current medication
  • Medication allergies
  • Smoking history
  • Family history of breast or ovarian cancer
  • Genetic testing results, when available

Pathology

  • Biopsy pathology report
  • Surgical pathology report, when applicable
  • ER result
  • PR result
  • HER2 result
  • Ki-67, when reported
  • Tumor grade
  • Lymph-node pathology
  • Genomic assay results, when performed
  • Original pathology slides or paraffin blocks, when requested

Imaging

  • Mammography
  • Breast ultrasound
  • Breast MRI
  • CT imaging, when performed
  • PET imaging, when performed
  • Bone imaging, when performed

Imaging should be supplied in original DICOM format whenever possible.

Photographs of printed films or screenshots may not be adequate for review.

Previous treatment

  • Operative reports
  • Chemotherapy regimen and dates
  • Endocrine therapy
  • HER2-directed treatment
  • Radiotherapy summary and treatment fields
  • Previous breast implants or reconstruction records
  • Hospital discharge summaries
  • Complication and readmission records

Translation

Medical reports should be available in English or Korean whenever possible.

A translation should preserve the original terminology, measurements, dates and test results. Do not replace the original report with an informal summary.

Protecting medical information

Medical records contain sensitive personal information.