The step families most often underestimate: getting the documents in hand in Malaysia. It takes more time than booking tickets or applying for a visa, and once the documents are incomplete every step after it has to wait — pathology missing immunohistochemistry, imaging available only as photographs of film, a discharge summary with no physician’s signature: the systems at Chinese hospitals accept none of it.
This article explains which items you need, how the GH and private hospital pathways work, and why getting the disc matters far more than taking a photo and sending it over. Procedures and charges differ considerably between hospitals, and each hospital’s current rules govern; what this article provides is the process skeleton and the criteria for judging.
1. First, distinguish the four kinds of documents you need
| Document | Held by | Application counter | Common problems |
|---|---|---|---|
| Discharge summary, inpatient records, outpatient records | Hospital medical records department | Medical records counter, application form required | Malay version only; missing the attending physician’s signature or the hospital letterhead |
| Pathology report and specimens | Pathology department / laboratory | Pathology department or medical records department | Report missing antibody clone numbers and scoring values; slides must be requested separately |
| CT / MRI / PET-CT original imaging | Radiology department | Radiology counter | Only printed film is given, not the original series |
| Laboratory and genomic testing reports | Laboratory / external reference laboratory | Laboratory or the issuing laboratory | Only the conclusion page is given; the testing platform and raw loci are missing |
Of these four, the third is the one most likely to stall. See section 4.
2. The GH (government hospital) pathway
Document requests at government hospitals are bound by the hospital’s internal rules, and the process usually involves one more level of sign-off than at a private hospital.
| Step | Where to go | What to prepare | Points to note |
|---|---|---|---|
| 1. Confirm where the documents are | The medical records department of the hospital where you were treated | Patient identity document, appointment card / registration number | Records are not shared between hospitals and must be requested separately |
| 2. Complete the application form | Medical records counter | Application form, proof of identity; a letter of authorisation if someone else collects | Some hospitals require the purpose to be stated (for example “second opinion” or “treatment abroad”) |
| 3. Sign-off | The treating department / the physician in charge | Depends on the hospital’s requirements | This is the step that takes the most time; explain the purpose to the department at the same time |
| 4. Pay and collect | Cashier → medical records department | Acknowledgement slip | The hospital charges per page or per set; the amount is set by each hospital |
| 5. Handle imaging separately | Radiology department | Imaging request form | Often has to be done at the radiology department separately, not at the same time as the medical records |
| 6. Handle pathology separately | Pathology department | Pathology request form | Slides and blank slides must be requested separately; paraffin blocks are generally not lent out |
Expected timing: how long the full set takes from application to collection depends on the hospital and the pace of sign-off; allow a buffer of more than a week, and put it ahead of your travel planning.
3. The private hospital pathway
Private hospitals usually have a dedicated medical records office and a customer service counter, so they are relatively efficient — but the rules still differ from hospital to hospital.
| Stage | Common practice | What matters when dealing with a Malaysian private hospital |
|---|---|---|
| Medical records application | Fill in a form at the counter, pay, collect at an appointed time | Some hospitals allow same-day collection, others need 1–3 working days |
| Attending physician’s consent | Some hospitals require the attending physician’s sign-off | Contact the attending physician’s secretary in advance; it is faster than queueing at the counter yourself |
| Imaging export | The radiology department issues a disc (DICOM) | State clearly: “original series, not compressed images” |
| Pathology slides | The pathology department arranges a slide loan or prepares blank slides | A loan usually requires a deposit and has a return deadline |
| Bilingual reports | An English version can be requested | Reports from Malaysian private hospitals are mostly in English, which is exactly what Chinese hospitals need |
The core difference between private hospitals and GH is predictability: a private hospital can usually give you a definite collection date, while GH depends more on the pace of sign-off. This is also what many families do — complete the diagnosis and the document preparation at a private hospital, and decide afterwards where the treatment will take place.
4. Why it has to be raw DICOM data
This is the single most important point in this article. The imaging system at a Chinese Grade 3A hospital reads a raw slice series, not images.
| What you have | What a specialist can do with it | Conclusion |
|---|---|---|
| DICOM original series (a disc exported by the hospital, or a compliant cloud link the hospital provides) | Adjust window width and level, multi-planar reconstruction, lesion volume measurement, comparison with previous studies | Usable: a form the imaging system can reconstruct from; a disc and a hospital-provided cloud link are equivalent, but confirm the receiving side can open it |
| Printed film | Can be viewed, but not measured or reconstructed | Reference only; you will usually be asked to supply the raw data |
| A photo of the film taken with a phone | Practically impossible to interpret | Not usable |
| JPG / PDF screenshots exported by the hospital | Cannot be reconstructed or quantified | Not usable |
When requesting, this sentence is the most effective: “Please export the DICOM original series, not compressed images.” Some hospitals supply images by default, and you have to ask explicitly.
5. Pathology slides and blank slides
Slides are needed when a rare mutation is involved, when immunohistochemistry has to be repeated, or when additional genomic testing is required.
| Item | Common practice | Reminder |
|---|---|---|
| Slide (stained) | Can be requested on loan, usually with a deposit and a return deadline | Keep it safe while it is on loan; if it is damaged it is difficult to replace |
| Blank slide (unstained slide) | Can be requested to be prepared, for the other side to repeat the IHC | Preparing blank slides takes time; request them in advance |
| Paraffin block | Generally not lent out | Where the original laboratory must lend it or cut the sections on its behalf, use the laboratory-to-laboratory channel |
| Consultation | The receiving hospital issues a pathology consultation opinion | This is a different matter from “borrowing slides” — do not confuse the two |
6. Six common causes of delay
| Cause | Consequence | Handle it in advance |
|---|---|---|
| Only the medical records were requested, and the imaging was forgotten | It still has to be supplied after arriving at the hospital | Request the medical records and the imaging at the same time |
| The hospital gives images by default rather than the original series | It has to be exported again | Write “DICOM original series” when applying |
| The discharge summary lacks a signature or letterhead | You are asked to have it reissued | Check the signature and the hospital emblem on the spot when collecting |
| The pathology report lacks antibodies and scoring values | The specialist cannot determine the subtype | Request the full report (including the IHC details) |
| Records are usually not shared between hospitals | You have to visit several hospitals | List all previous visits and apply to each one; interoperability between government hospitals is improving, but whether a given hospital can retrieve them is for the hospital to confirm |
| You cannot find the format of the authorisation letter | Collection on someone else’s behalf is refused | Ask the hospital in advance what the letter of authorisation must contain |
7. How to organise everything once you have it
It is worth assembling a “submission pack” in the order below — the same logic Chinese hospitals use when accepting a case:
- Diagnosis and staging: the latest discharge summary / outpatient record, and the pathology report (including IHC)
- Molecular subtyping: the genomic testing report (including the testing platform and loci)
- Imaging: the DICOM disc (or a compliant cloud link) plus the imaging reports
- Treatment history: each previous regimen, and the medication list (drug name, dose, cycle, start and end dates)
- Current status: the most recent laboratory reports and a description of performance status
Once everything is organised, you can move to the next step: /artikel/second-opinion-malaysia-to-china-48h/. The submission channel on the platform is at /hantar-kes/.
8. Frequently asked questions
Q: Can I collect a family member’s documents myself if I only bring my own identity document?
A letter of authorisation is usually required. GH and private hospitals have different requirements for the letter, so it is best to telephone the medical records department first and ask clearly, rather than making a wasted trip.
Q: The hospital says the records can only be given to the patient in person. What can I do?
You can start by applying for a “copy for patient review”; where the records are to be handed to a third party, the hospital will usually require written consent. The hospital’s rules govern.
Q: Is there a charge for the imaging disc?
Most hospitals charge by the number of discs. The amount is not large but differs between hospitals; it is worth taking cash or a usable payment method.
Q: Will Chinese hospitals accept the English reports and slides obtained in Malaysia?
They accept DICOM imaging and standard English pathology reports that follow international practice; the key is that the material is complete and can be re-reviewed. If testing has to be repeated on the slides, this goes through the pathology consultation channel.
Q: The medical records are my personal data — can I require the hospital to provide them under the PDPA?
The PDPA gives data subjects the right to access and obtain a copy, and it also sets out conditions for cross-border transfer. The exact way to exercise that right, and the fees, remain subject to the current rules of the hospital and the supervisory authority.
This column explains the process and compliance points; it does not constitute legal or medical advice. Each hospital’s procedures, charges and time limits are governed by its current rules; whether a patient is accepted and which plan is used are determined independently by the treating physician team of the receiving hospital.
Reference sources
- Ministry of Health Malaysia, MOH (rules on medical institutions and medical record management): https://www.moh.gov.my/
- Department of Personal Data Protection Malaysia, JPDP (data subject access rights and cross-border transfer): https://www.pdp.gov.my/ppdpv1/hak-hak-subjek/
- Personal Data Protection Act 2010 (PDPA, Act 709), full text: https://www.pdp.gov.my/ppdpv1/akta/akta-pdp-2010-my/
- DICOM medical imaging standard (DICOM Standards Committee): https://www.dicomstandard.org/