When a medical report lands in my inbox I know it’s going to be a challenge. The format might be a scanned PDF or even a photo. It’ll be written in technical jargon, from one doctor to another, teeming with abbreviations, none of which will be glossed. In addition, the potential client may be hiring a translator for the first time ever and will need to be guided through the translation, invoicing and payment workflow.

First, a note if you have arrived here because you need Spanish medical records, discharge reports or other hospital files translated into English: please read the medical report page on my website and then complete the contact form. I’ll be happy to help you!

Primero, un comentario por si buscas un traductor al inglés para un informe médico, un resumen clínico de alta u otro documento relacionado: por favor, consulta la página sobre informes médicos de mi página web y rellena el formulario de contacto. ¡Me pondré en contacto contigo enseguida!

A complex puzzle

When I started translating over 20 years ago, I used to dread medical reports for all the above reasons. But over the years, I’ve become familiar with common Spanish medical abbreviations and learnt strategies to research unfamiliar ones. I’ve developed an eye for a Spanish doctor’s handwritten t, d and l, and intuition for adding missing pieces to the puzzle. Based on my experience, here are some tips for translating medical reports efficiently.

1. Agree on what needs to be translated

A client may not need a 20-page report translated word for word. I sometimes offer an adapted or summarised translation service, especially if there are time or budget constraints. The exact content depends on the purpose of the translation.

Potential sections for adapting or deleting from the translation:

• Hospital reports issued on complex forms are sometimes only half completed. Ask your client if you can omit blank fields if they are not relevant.
• Abnormal lab results are usually starred or marked with an up or down arrow to show that they are out of the reference range. Ask if you can just translate the abnormal results and attach the full version in the source language only.
• The patient’s name, address, bed number and medical record number may appear scores of times in a long medical report. Suggest translating these details just once, the first time they appear. Or not at all.

You’ll need to use your discretion when offering this type of service. If you don’t feel confident about what you can omit, translate the whole report. If the translation is for a different purpose, such as an insurance claim, then you’ll need to translate the document exactly as is.

Personal details should be redacted if the report is part of clinical trial documentation. This preserves the blinding process and protects privacy.

2. Arrange prices, invoicing and payment before you start

Make sure these details are all tied up in advance. Think carefully about your quote. Charge a fixed price that will cover the time you need to complete the whole project. A per word rate won’t apply for this type of text, which may be scanned, have abbreviations to research and need more time than usual to format.

Don’t forget to tell your client whether VAT will be applicable. (In Spain, the invoice will be subject to VAT unless the client lives outside the EU.) Payment should be on receipt of the invoice. Upfront payment is advisable; you can still make a start on the translation while you’re waiting for the transfer to come through.

3. Use an OCR tool

If the report is scanned, I recommend Abbyy FineReader to convert the text into an editable format. Make sure you prepare tables in Abbyy, and then convert the file in plain text to Word and complete the basic formatting there. Exact copies with hospital logos are probably going to be overkill for a medical report.

Revise the converted text carefully. Be particularly wary of typical OCR errors. “1” and “I” and “0” and “o” look very similar in some fonts (2o March 2oI5). Certain letter combinations can be misinterpreted by an OCR tool, especially in the case of proper names that aren’t in the dictionary (e.g., “Emesto” instead of “Ernesto”).

Why not just start with a blank Word document?

I use OCR for two reasons. First, to save time copying long numbers, names and addresses, and second, to translate the source file in a CAT tool. In Trados Studio I’ve built up a good medical glossary over the years, full of drug names, procedures and abbreviations.

4. Decipher unknown abbreviations

This is usually the most time-consuming part of the translation. A 300-word medical report splattered with abbreviations isn’t going to be a 30-minute job. The standard recommendation to “ask the client” when you have doubts doesn’t apply here. If your client is the patient, or even an agency, they won’t be able to help you.

Strategies for solving abbreviations:

• For Spanish abbreviations, Cosnautas is THE place to go. Access to Siglas médicas en español is free of charge; you simply have to register. The latest version, released just a few days ago, contains 30,000 entries and 90,000 meanings.
• The abbreviation might be in English already. Check it out at MediLexicon, an excellent resource for English medical abbreviations.
• Search on translators’ terminology forums. If you don’t find the answer, post the abbreviation to see if a colleague can help.
• When you discover what the abbreviation stands for in your source language, find the equivalent in English (or your target language). Try entering the meaning in Google, together with the word abbreviation.
  Don’t worry if you can’t find the target abbreviation. Gloss the meaning rather than inventing an abbreviation yourself.
• Look for other clues. Is the abbreviation in the blood results’ section? Is it a procedure? Is it written out in full later on in the report?
• Is it simply someone’s initials?
• As a final resort, try ringing the hospital in question. The phone number and department extension is often on the report itself. Without disclosing the patient’s identity, explain why you need to find out the meaning of the abbreviation. It may be an in-house term that the hospital can solve for you in 30 seconds.

5. Deal with drug names

Doctors often use common brand names for drugs in medical reports. Don’t replace them with equivalent brand names in your target language. Keep the source name and add the INN (International Nonproprietary Name) in brackets afterwards. The WHO MedNet INN database gives INNs in Arabic, Chinese, English, French, Latin, Russian and Spanish.

6. Check the legibility of handwritten texts

When working out your estimate, take into account the extra time you’ll spend reading and interpreting handwritten sections. Only accept handwritten texts if you feel confident you can decipher them. Inserting illegible where there is core content will make the end translation unfit for purpose. Misinterpreting a poorly-written number could have even more serious consequences.

7. Confidentiality

Medical reports are highly confidential documents that contain personal and sensitive health data. Make sure your workflow respects data privacy and security.

A final tip:

Don’t take on the job if you’re out of your depth. If you don’t understand the medical content of the report or will be playing a guessing game with the abbreviations, recommend a more experienced colleague instead.

I hope these tips come in useful the next time a medical report drops into your inbox.

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