Organizing Your Medical Records

Overview

Each clinical trial will review your medical history to determine if you are eligible to enroll and receive treatment. When you find a clinical trial of interest you will¬† ask your oncologist to provide the clinical trial coordinator with the documents needed to medical history. It’s OK if you don’t know exactly what you need. Our team put together step-by-step instructions to guide you through this process.

Step 1: Print Out the Medical Record Checklist

Cure-Hub.org developed a checklist of information needed to enroll in a trial. Download our Medical Record Checklist by tapping or clicking the image below.

Cure-Hub.org's Medical Record Checklist
Cure-Hub.org’s Medical Record Checklist

Step 2: Ask Your Your Doctor’s Office To Fill Out Medical Record Checklist

Your doctor’s office has all the necessary information and you can ask them to complete the Medical Record Checklist.¬† Tell their office that you need your records because you plan to enroll in a clinical trial. It is not necessary to have your physician fill out this form, the nursing and/or office staff should be able to handle it.

Step 3: Get Copies Of Important Reports in Your Medical Record

Most trials will want copies of original reports in your medical file. Ask your doctor’s office to help you obtain the necessary reports. Below is a list of reports that you want to collect:

Progress Notes

These notes are written by your doctors and nurses. They contain information about your clinical status, treatment plans and response to treatment. These progress notes are used by clinical trials to assess your eligibility.

Diagnostic Imaging Reports

These reports describe the results from diagnostic imaging procedures that have been performed. Examples of diagnostic imaging include MRI, X-RAY, CT, MUGA and PET scans.

Surgery Reports

Each time a surgical procedure is performed, the surgeon will prepare a report describing the surgery and outcome.

Pathology Reports

After a biopsy or tumor resection, samples of your tumor will be sent to the pathologist for examination. The pathologist will prepare a report that describes their findings. This information is used to determine the specific type of cancer, and to refine treatment options.

Treatment Reports

Your oncologist may order many different kinds of treatment, including chemotherapy, radiation, targeted therapy, hormone therapy, immunotherapy, etc. The treatment reports include detailed notes about the medications, dosage, objectives and patient’s response.

Laboratory Test Results

Lab tests are an integral part of cancer treatment. Common lab tests include blood work (eg. Complete Blood Counts, Metabolic Panels) and urine analysis. You should try to obtain copies of all lab test results for the prior year.

Other Reports

The above list includes many of the most important reports, but it is not all-inclusive. Your goal should be to get as many of the reports in your medical file as possible. This will make the clinical trial application process most efficient.