Translation of discharge summaries and medical histories

A discharge summary is the document that follows the patient from one doctor to another, from one clinic to another and often from one country to another. It is on this document that the receiving doctor decides whether to continue the treatment already started, change it or order additional tests. That is why translating a discharge summary is not simply carrying over text: it is ensuring continuity of treatment. We translate discharge summaries, case histories, outpatient cards and consultation reports from Georgian into foreign languages and back, always with a medical-profile translator and a second specialist as editor.

What kinds of documents are involved

In practice the term "epikrisis", as it is called in Georgia, covers several different documents, and each has its own structure and translation specifics:

• Discharge summary: the summary issued on discharge from hospital, covering the diagnosis, the treatment carried out, the description of the operation and recommendations
• Transfer summary: on transfer from one department or clinic to another, where an exact description of the current therapy is critical
• Interim summary: an intermediate summary of long-term treatment, often in oncology and rehabilitation
• Case history: the full inpatient record with daily notes, prescription sheets and all test results
• Outpatient card: years of notes from different doctors, often handwritten
• Consultation report: a one-off assessment by a specialist, sent abroad for a second opinion

The structure of a discharge summary and the translation risks

Anamnesis and complaints

In the anamnesis section the doctor conveys the patient's words in medical language. Here the translation must preserve two things: the exact character of the symptom (for example, "sharp" and "dull" pain imply different diagnostic directions) and the chronological sequence. Georgian discharge summaries often contain phrases such as "has considered himself ill for 2 years", which must be rendered in English according to the clinical standard ("2-year history of"), not word for word.

Diagnosis and ICD codes

The diagnosis is the highest-risk part of the summary. In Georgian practice the diagnosis is often written in Latin or in a mixture of Latin and Georgian terms, while comorbidities are in a separate block. We preserve the hierarchy of the principal, concomitant and complication diagnoses, carry over the ICD-10 codes unchanged and match the Latin term with the clinical equivalent of the target language. For example, "Insultus ischaemicus" becomes "ischemic stroke" in an English summary and "ischämischer Schlaganfall" in a German one, not the Latin form, which is no longer used there.

Treatment carried out and medicines

In the medicines block every entry consists of three elements: the drug, the dose and the regimen. We give the drug by its trade name and, where needed, by its international nonproprietary name (INN), because the same active substance has different trade names in different countries. The dose and regimen ("1 tab. twice a day after meals") are double-checked, and in the case of intravenous therapy, chemotherapy cycles and anaesthesia records every number is compared with the original.

Description of the operation and recommendations

In the description of a surgical intervention the terminology must be anatomically exact: the approach, the stages, the type and size of the implant, drainage. The recommendations section is the text the patient will read themselves, so the translation must be both medically exact and understandable.

The specifics of a Georgian discharge summary that a foreign translator cannot see

Georgian medical documentation is historically a mixture of the Russian-language and the Latin tradition. This creates several particularities:

• abbreviations that are in no international dictionary: the local short forms for a complete blood count, ECG, ultrasound examination and so on
• a Latin diagnosis in the Russian tradition, which remains incomprehensible to an English-speaking doctor
• seals, signatures and handwritten additions, which must be fully reflected in the translation
• Form 066 and other standard forms whose structure does not exist in a foreign system

Our translators know this system from the inside, so a Georgian discharge summary becomes an English, German or Turkish document that the receiving clinic accepts without additional questions.

Two directions: treatment abroad and medical tourism

We translate from Georgian into a foreign language when a patient plans treatment at a clinic in Turkey, Germany, Israel, the USA or another European country and has to send the full history before admission. Here speed is often critical, because the clinic's response and the quota depend on the translation.

We translate from a foreign language into Georgian in two cases: when a foreign patient comes to Georgia for treatment and the Georgian doctor needs their history, and when a Georgian patient returns after treatment abroad and continues follow-up here. In both cases the fact that the same team works in both directions ensures terminological consistency.

Certification: when you need what

• For a doctor or a clinic: a professional translation with the agency's seal is enough, which confirms completeness and correspondence to the original
• For an insurance company: usually a translation certified with the agency's seal, sometimes notarized
• For a court, a pension or social service, disability status: a notarized translation, and for submission abroad an apostille as well

We establish the purpose when taking the order and advise only the level you really need.

How we prepare the translation of a discharge summary

• we preserve the structure of the original: headings, blocks, tables, dates and the patient's identification data stay in the same place
• we describe seals and signatures in square brackets, so that the recipient knows what was on the original
• an illegible handwritten fragment is marked with a translator's note and never filled in by guesswork
• for a patient who has several summaries and tests we create a single terminology base, so that all the documents speak one language
• a second medical specialist compares the diagnoses, doses, dates and numbers with the original line by line

Frequently asked questions