What tests and medical records say: terms and questions for your clinician

One result is one part of the picture

Laboratory tests, imaging and tissue examination answer different questions. A result outside the reference range does not establish a diagnosis on its own, and a value within the range does not rule out a problem on its own. Your clinician interprets the results together with your symptoms, medical history and other investigations.

This guide explains how the documents are structured. It does not interpret individual results.

A laboratory report may include:

• the name of the test;
• the measured value;
• the unit of measurement;
• the laboratory's reference range;
• flags such as low, high or critical.

Ranges and units can differ between laboratories. Compare results over time only with help from your care team, especially if the method or laboratory has changed.

Common terms include:

• haemoglobin: a protein in red blood cells that carries oxygen;
• white blood cells: cells involved in the body's defence against infection and disease;
• platelets: blood components that are important for clotting;
• tumour marker: a substance made by cancer cells or by other cells in response to cancer or certain non-cancerous conditions. A marker cannot confirm cancer on its own.

A CT, MRI or PET-CT report usually describes why the examination was done, the technique used, what the radiologist observed and a conclusion. Words such as "lesion", "nodule" or "uptake" describe an observation. On their own, they do not say that it is cancer.

Ask which finding matters, which previous examination it is being compared with and whether another investigation is needed.

A pathology report is written by a pathologist after examining cells or tissue obtained through a biopsy or operation. It may include:

• the site and type of sample;
• a macroscopic and microscopic description;
• the pathological diagnosis;
• tumour grade;
• margin and lymph node status, when relevant;
• immunohistochemistry or biomarker results;
• tests that are still in progress.

• biopsy: removing cells or a piece of tissue for examination;
• benign: not cancerous;
• malignant: cancerous;
• tumour grade: describes how different the tumour cells look and gives information about their likely behaviour;
• stage: describes how far the cancer has spread in the body; it is not the same as grade;
• negative margin: no cancer cells were found at the edge of the removed tissue;
• positive margin: cancer cells were found at the edge;
• positive lymph node: cancer cells were identified in the lymph node examined;
• immunohistochemistry: a test that uses antibodies to identify specific proteins in tissue;
• biomarker: a biological feature that may provide information about the cancer and, in some situations, treatment options.

The exact meaning depends on the type of sample and the clinical context. Do not use these definitions to determine prognosis or treatment on your own.

• What is the main conclusion of this result?
• What is still unclear or in progress?
• How does it relate to the other investigations?
• Does it change the diagnosis, stage or plan we discussed?
• Is another sample, test or second opinion needed?
• Which exact term should I write down for the next appointment?

Patient portals may display the report before your care team has discussed it with you. Write down your questions and ask the clinician who knows your case to explain it. Do not make treatment decisions or stop medicines based on an online interpretation.

Identify the type of document, its conclusion, what is still in progress and your questions for the team. Your role is not to translate the entire medical record alone, but to arrive at the appointment with clearly defined questions.