Sometimes, getting a second opinion may seem a complicated process, especially, because knowledge of patient’s medical history is crucial for the proper cancer diagnosis. This article will present data needed for second opinion, and the best ways for obtaining it.
As pathology reports are mostly used for communication between pathologists and other specialists, sometimes patients do not even receive them, and they are informed about their final diagnosis orally by the attending physician. However, patients are increasingly aware that the pathology report is the most important document in the entire diagnostic process, greatly impacting the further treatment. For this reason , more and more often they decide to verify it by requesting a second opinion.
Unfortunately, many patients do not know what documents are necessary for this purpose and how to get them. Therefore, we will try to explain, step by step, how to prepare the required documentation that will be used to obtain the most complete second opinion possible.
Handling Medical Informationa
Medical records regulations vary from country to country and sometimes even within one country. On some occasions, a patient receives only basic med info, often just in an oral form. In other cases, after each visit to a doctor or stay in the hospital, the patient receives a thick folder containing a lot of, sometimes unnecessary, information about all tests and observations carried out. As a general rule, however, having too much information is better than not having enough, so we always encourage patients to request complete records after each of their hospital stay.
Medical records needed for a second opinion
The process of formulating a second opinion on a pathology diagnosis is similar to the preparation of the first pathology report. The main difference here is the fact that during the initial diagnosis, the patient is often under the care of a physician cooperating with a laboratory and a pathologist performing the examination, which simplifies the process of obtaining additional information about the patient and conducting additional tests. The doctor responsible for the second opinion will rely mostly on the documents provided to them, therefore it is important to ensure that this documentation is as complete as possible.
Of course, to prepare a new pathology report, it is necessary to have histo- or cytopathological material in the form of microscopic slides or their scans. If the opinion is to be supplemented with additional tests, such as immunohistochemistry or molecular pathology tests, it is also necessary to send paraffin tissue blocks to a laboratory performing the evaluation. What is important, an assessment of the entire material (all slides evaluated in the original examination) is required to produce a valid opinion.
Laboratories providing second opinions usually have their own forms used to obtain basic information about the patient, such as their sex, age, place of residence and basic clinical data about the disease. The most important documents that should be attached to the application include the full primary pathology report, which is to be verified by the second opinion, and without which such opinion should not be issued.
What more should be in a personal medical record?
Another essential element of the medical records are the results of radiological imaging. They include written interpretations of performed scans, as well as the original images in case of X-ray, CT or MRI. Ultrasound examinations usually are not recorded, so the interpretation of the examination itself is sufficient. If the patient has had many radiological tests performed as part of the diagnostic process, it is best to provide all available results. If the diagnosis refers to a skin lesion, it is highly recommended to attach its photograph.
Another important element of medical records required in the process of obtaining a diagnosis is a summary of the procedures performed so far and the treatment received, most often in the form of a discharge summary issued by a health care facility responsible for the treatment. Such summary should also include medications taken at time the biopsy was performed, as well as other diseases that the patient has. If laboratory tests were carried out during the process of diagnosis and treatment, especially those concerning the so-called tumour markers, their results should also be included in the documentation. Information about other cancers and chronic diseases running in the family, as well as potential occupational exposures can also be helpful to establish a diagnosis in some cases.
If we are unable to obtain any of the information from the above list, it does not mean that receiving a valid second opinion is impossible, as long as it is possible to evaluate the microscopic slides. However, in some cases this may make the process more time-consuming, and may require additional contact with the patient or their relatives.
How to obtain your medical data?
We recommend patients to always ask for a copy of their medical records and keep them safe. However, if you have not received a printed version of your documentation after staying in a hospital or other health care facility, usually, the best way is to contact the place where the treatment or diagnostic process took place. In developed countries, health care facilities are responsible for preparing and archiving of medical records, and they are obliged by law to issue their copy on the patient’s request. However, we must be aware that obtaining complete documentation, especially from large medical centres, can be a time-consuming process. In some countries, it can be facilitated by the use of online national medical databases, although they rarely contains medical records created before the database was launched.
As a rule of thumb, medical facilities should be willing to help with preparing of documentation required for a second opinion. It should be borne in mind that if the documentation is requested by the patient’s close relative, and not by the patient themselves, usually they will be required to present an appropriate written authorization from the patient or to confirm their status of the patient’s legal guardian.
Procedures for renting paraffin blocks and slides for second opinion vary from country to country and even between different laboratories within the same country. Therefore, the best solution is to directly contact a relevant laboratory and ask about their procedures. As a rule, all laboratories are obliged to borrow the material on the patient’s request. Furthermore, pathologists following the professional code should willingly submit their reports to the verification process, being aware how important a correct diagnosis is for the further fate of the patient.
Who can help you obtain medical information?
When obtaining medical documentation or pathology samples (slides and blocks) is problematic for the patient for various reasons, it is worth asking a doctor in charge of your case for help, as they may request such documentation to be prepared, on behalf of their patient. In some countries, the patient will need to prepare a written authorization for their physician, so they can request the documentation.
Of course, if you still have any difficulties with obtaining documentation or have some doubts about documents required in a particular case, we encourage you to contact our company personally, so we can assist you in the best way possible.
Author: Adam Gorczyński, MD, PhD
Image: https://wirtualnymikroskop.mostwiedzy.pl/