What documents do you need for a second opinion?

Why documentation decides the quality of the answer

A specialist giving a second opinion wasn't present for any of your care. Everything they know comes from what's in front of them. A well-documented case gets a considered answer; a thin one gets a heavily caveated answer, or no answer at all.

That's why it's worth spending time on this step. It's the part you control.

The core list

Referral letters — the original referral that started this episode of care, and any onward referrals. These usually contain the clearest statement of the clinical question.

Imaging and scan reports — CT, MRI, X-ray, ultrasound, PET. The report is the radiologist's written interpretation and is what most reviewers work from. If your question is specifically about the imaging itself, the actual images matter too — see below.

Pathology and blood test results — including the dates. Trends over time often matter more than any single result.

Specialist letters and correspondence — letters between your specialists and your GP. These carry the reasoning behind decisions, which is frequently the most useful material in the whole file.

Hospital discharge summaries — for any admission, procedure or operation.

Medication list — current medications and doses, plus anything recently stopped and why.

Operation or procedure reports — the surgeon's own account of what was done and found.

Images versus imaging reports

These are different things and people often send one thinking it's the other.

The report is text: the radiologist's findings and impression. The images are the scan files themselves, usually in DICOM format, supplied on a disc or through a patient portal from the imaging practice.

For most second opinions the report is enough. If the question is whether the imaging has been interpreted correctly, a reviewer needs the images. Ask the imaging practice directly — they hold them, not your specialist, and they'll generally provide a copy or a secure link on request.

How to request records you don't hold

You have a right to access health information held about you — under the Privacy Act 1988 for private practices and imaging providers, and under state or territory legislation for public hospitals. In practice:

• GP records — ask the practice manager. Most practices have a form.
• Hospital records — ask for the medical records or health information department. Public hospitals have a formal process and may charge a fee.
• Imaging — go to the imaging practice that performed the scan.
• Pathology — usually easiest through whichever doctor ordered the test.

Allow a couple of weeks. Some providers respond in days; hospitals often take longer.

What if there are gaps?

Send what you have. A reviewer would rather see an incomplete file and know what's missing than receive a tidy-looking file with a silent hole in it.

If something important is missing, a good review process will tell you before proceeding rather than working around it. At Otro, if we can't answer your question with what's available, we say so at triage and you aren't charged.

What not to send

Don't send anything relating to another person. Don't send altered documents — a modified record makes the whole file unreliable. And you don't need to send your entire medical history from birth: focus on the condition in question and roughly the last few years, unless there's older history that's directly relevant.