Medical Records for an MS Consultation in China: Showing How the Disease Has Changed

The most useful MS record explains what happened, when it happened and which treatment was being used at the time. A large folder can still leave those questions unanswered. International consultations add further difficulties: scans may be stored by several hospitals, medicine names differ across countries, and dates may be written in different orders. Organising the evidence before departure gives the specialist more time to discuss the decision that brought you to the appointment.

Key takeaways

These excerpts come from the original article. Read the full sections below for context.

Write the current diagnosis, who made it and when. If it remains provisional, retain that uncertainty. Then identify your present disease-modifying treatment, the most significant recent change and the questions you want answered. For example, gradual loss of hand function without an obvious attack raises a different discussion from a new lesion on the first scan after a drug switch. A clear question helps the receiving team decide which records are essential.
For a history of optic neuritis or other visual problems, bring existing acuity, visual field, ophthalmic, OCT and visual evoked potential results, with the symptoms present at the time. The consensus accompanying the new diagnostic framework explains how OCT and VEP may support evidence of optic nerve involvement, subject to appropriate quality and interpretation. Other eye disease and technical factors matter; a single number should not be used by the patient as a diagnostic shortcut. Consensus on OCT and VEP
A translation should preserve original page references, generic drug names, numbers and units. Mark unclear handwriting for confirmation. Keep the source documents beside the translation so that the clinician can check them. Expressions such as “not demonstrated,” “cannot exclude” and “increased compared with the previous study” should retain their meaning; replacing them with a more confident phrase can change the medical interpretation.

Quick answer

Full guide

Begin with a short account of the unresolved question

Write the current diagnosis, who made it and when. If it remains provisional, retain that uncertainty. Then identify your present disease-modifying treatment, the most significant recent change and the questions you want answered. For example, gradual loss of hand function without an obvious attack raises a different discussion from a new lesion on the first scan after a drug switch. A clear question helps the receiving team decide which records are essential.

The 2024 McDonald revisions changed parts of the diagnostic framework. Earlier assessments and the evidence supporting them remain relevant when a specialist reviews the diagnosis today. Keep the original wording and the later developments together; do not rewrite an old “possible” finding as definite simply to make it appear to satisfy newer criteria. Updated McDonald diagnostic criteria

Date the summary and identify who prepared it. Separate recollection from documented findings: “approximately that spring, according to the patient” is different from a date recorded in a discharge letter. If the exact date cannot be recovered, an honest range is preferable to an invented day. Use an unambiguous format for translated dates, and check that the year, month and day still match the source document.

Describe recovery as well as the beginning of an episode

For each major neurological event, note the initial symptoms, how long they lasted, whether infection or fever was present, the activities affected and what happened after treatment. Include gradual changes too, such as beginning to use a handrail or needing longer recovery after walking. A timeline limited to hospital admissions can overlook the functional changes that matter most at home. NICE includes relapse assessment and broader functional review within MS care. NICE recommendations

Avoid labelling every difficult day a relapse yourself. If old symptoms returned during a urinary infection or a hot period, record the circumstances. If steroids were given, describe the subsequent course rather than writing only “responded well.” Explain which symptoms improved, how soon, and what remained. Attach the clinician's assessment when available so that the receiving doctor can distinguish the contemporary interpretation from your later recollection.

The purpose is not to create a perfect autobiography. Start with the events most likely to affect diagnosis or the next treatment decision. A concise index can direct the doctor to the supporting reports. If an important admission record is missing, name the hospital and approximate date and mark it as unavailable. That is more useful than silently leaving a gap that could be mistaken for a period without disease activity.

Supply complete MRI studies, not only selected pictures

Ask the imaging provider for the original study in a format that another medical institution can review, usually DICOM, as well as the official report. Photographs of films or a few screenshots do not contain the full series. DICOM standardises medical imaging information exchange, but it does not guarantee that every receiving system will read every supplied package successfully. Test the files and ask the hospital about its accepted transfer method before travelling. DICOM introduction and overview

Identify the body region, date, imaging centre and whether contrast was used. Prioritise examinations relevant to the original diagnosis, treatment initiation or switching, and new symptoms. The 2024 MRI consensus emphasises suitable acquisition, interpretation and communication of diagnostic imaging. This is a reason to preserve what was actually done, not a requirement for patients to commission every specialised sequence independently. 2024 consensus on diagnostic MRI

Conflicting descriptions such as “more lesions” and “unchanged” should prompt comparison of the studies rather than an assumption that one report must be wrong. The acquisition method, image quality and choice of earlier comparison can affect interpretation. Note whether the reporting radiologist had the previous images available. Guidance on MRI monitoring also addresses consistent comparison, which is why earlier examinations can remain useful even after a newer scan has been performed. MRI diagnosis and monitoring consensus

Do not discard the original folder structure merely to make the files look tidier. Place each examination inside a dated folder, and keep any supplied viewer separate from your written index. A cloud link should be tested for access and expiry. If the hospital cannot use the proposed system, resolve that before arrival instead of discovering the problem during a short appointment.

Keep the detail behind cerebrospinal fluid and antibody results

Obtain the complete lumbar puncture laboratory reports where possible. “Oligoclonal bands positive” alone may omit information the specialist needs. If kappa free light chain measures were obtained, retain the method, units, reference range and relevant paired blood results. The newer evidence framework allows their use in suitable circumstances, but a marker cannot establish MS independently of the clinical context. Recommendations on cerebrospinal fluid kappa free light chains

Include existing AQP4-IgG and MOG-IgG reports in the differential-diagnosis section. Preserve the sampling date and any treatment being given at the time. NMOSD and MOG antibody-associated disease have their own diagnostic requirements; a negative result or a low positive result needs interpretation in context. A translation should not turn a particular test result into the much broader statement that every alternative disease has been excluded. NMOSD diagnostic recommendations, MOG antibody-associated disease criteria

Distinguish three different situations: the test was not performed, the result cannot be found, or the result was within the stated range. This prevents missing information from being treated as negative evidence. If a scan of a report cuts off the units or laboratory comments, request a complete copy. Resist the temptation to retype an unclear number from memory; mark it for verification instead.

Preserve visual and functional assessments beyond the headline score

For a history of optic neuritis or other visual problems, bring existing acuity, visual field, ophthalmic, OCT and visual evoked potential results, with the symptoms present at the time. The consensus accompanying the new diagnostic framework explains how OCT and VEP may support evidence of optic nerve involvement, subject to appropriate quality and interpretation. Other eye disease and technical factors matter; a single number should not be used by the patient as a diagnostic shortcut. Consensus on OCT and VEP

Arrange previous disability, walking and hand-function measurements by date if they are available. Add a short account of the change you actually notice: slower writing, falls, difficulty preparing a meal, or fatigue affecting work. A formal score may not capture every important daily problem. Where appropriate, ask whether the clinic will accept a dated symptom video; it can provide context but cannot replace a neurological examination.

If rehabilitation is the main reason for the visit, include the therapist's assessment, the exercises already attempted and the activities you hope to regain or make easier. Mention what prevented a previous programme from continuing. The limitation may have been pain, transport, fatigue or lack of assistance rather than unwillingness to participate. That distinction can help the new team propose something feasible.

Document treatment exposure and why each medicine changed

For each disease-modifying therapy, list the generic name, formulation, start and stop dates, actual administration and reason for change. A brand name alone may be difficult to identify across borders. Explain whether discontinuation followed disease activity, an adverse effect, a pregnancy plan or an interruption in supply. If treatment was not taken as intended, say so plainly. Otherwise, an incomplete exposure may be interpreted as failure of an adequately delivered course.

For therapies such as ocrelizumab, infusion dates, infection screening and relevant monitoring belong in the record. The Chinese prescribing information describes the product's indications and safety requirements, but the clinical history must show what you personally received. Another patient's schedule, or a general leaflet, cannot substitute for your treatment administration record. Chinese ocrelizumab prescribing information

List symptom medicines, contraception, herbal products and supplements alongside MS therapies. Separate an allergy from other intolerance, and describe the event and its management. The FDA's glatiramer warning notes that serious allergy can occur even after long use and can overlap with some immediate injection reactions. Accurate details help the next clinician reassess the risk more effectively than a vague note that a drug “did not suit me.” FDA glatiramer anaphylaxis warning

Keep the most recent medication list easy to find rather than buried among historical prescriptions. Record the date it was checked. If two clinicians have given different instructions, retain both and identify the unresolved discrepancy. Do not silently choose one version while preparing the translation; ask the prescribing team to reconcile the list.

Include circumstances that affect the next decision

Pregnancy intentions, breastfeeding, recent infections, vaccination records, liver disease and care from other specialties may affect treatment discussions. The 2026 Association of British Neurologists pregnancy guidance places planning in the context of the specific disease-modifying medicine. Preparing for a pregnancy does not itself mean that every therapy should be stopped. 2026 guidance on MS and pregnancy

Also describe what can be delivered where you live: access to monitoring, availability of a clinician who can prescribe follow-on treatment and your ability to return to China. These facts do not alter the diagnostic evidence, but they influence whether a proposed course is workable. If finances or repeated travel are likely to limit a choice, raising the issue early gives the team a chance to discuss alternatives before a complex plan has been developed.

Check translations, authorisation and the way files will be shared

A translation should preserve original page references, generic drug names, numbers and units. Mark unclear handwriting for confirmation. Keep the source documents beside the translation so that the clinician can check them. Expressions such as “not demonstrated,” “cannot exclude” and “increased compared with the previous study” should retain their meaning; replacing them with a more confident phrase can change the medical interpretation.

When someone else collects records, check the institution's identity and authorisation requirements. Beijing Tiantan Hospital's official copying process distinguishes patient and proxy applications and describes online and in-person arrangements. Confirm its current requirements for the requested records; one hospital's process does not establish the rules at another institution or in another country. Beijing Tiantan Hospital medical record copying procedure

For electronic delivery, organise a readable index with dated sections for the summary, clinical course, imaging, laboratory findings, treatment and other relevant information. Verify the receiving channel and who is authorised to access it. Keep an offline copy and a short current medication list available without having to sign into several services. A temporary download link should not be the only way to retrieve essential information during a consultation.

Before leaving China, update the record with the new assessment, the reasoning behind treatment recommendations, pending results and responsibility for follow-up. If uncertainty remains, ask what evidence is needed to resolve it. The aim is a clinical history that continues to be useful: another clinician should be able to see what has been established, what has changed and which question still needs an answer.