# How to translate medical records in Spanish to English

Medical records in Spanish are called an expediente clínico in Mexico and a historia clínica in Spain and most of Latin America. For the immigration medical exam, the applicant provides reliable English translations of all vaccination records[1]. LoreAI turns a scan or photo of the records into an editable English Word file, with lab tables, doses and dates in place.

## What Spanish medical records are called

The name on the first page tells you what kind of record it is. Keep that name in the heading of the translation, followed by the English term.

- **Expediente clínico**: Medical record or patient chart, the term in Mexico
- **Historia clínica**: Medical history or clinical record, used in Spain, Colombia, Argentina and most of South America
- **Cartilla Nacional de Salud, cartilla de vacunación**: Mexican vaccination booklet, by age group
- **Carnet de vacunación**: Vaccination card, used in Spain and much of Latin America
- **Informe médico, resumen clínico**: Medical report, clinical summary
- **Epicrisis, informe de alta**: Discharge summary
- **Resultados de laboratorio**: Laboratory results
- **Receta médica**: Prescription

## Terms inside the record

*Common terms in Spanish medical records, with the English a translator would use*

| In the record | In English |
| --- | --- |
| Antecedentes personales patológicos | Past medical history |
| Antecedentes heredofamiliares | Family history |
| Padecimiento actual | History of present illness |
| Diagnóstico, impresión diagnóstica | Diagnosis, diagnostic impression |
| Tratamiento, indicaciones | Treatment, orders |
| Signos vitales: TA, FC, FR, temperatura | Vital signs: BP, HR, RR, temperature |
| Biometría hemática, hemograma | Complete blood count |
| Química sanguínea | Blood chemistry panel |
| Examen general de orina | Urinalysis |
| Dosis, refuerzo | Dose, booster |
| SRP, triple viral | MMR vaccine |
| Médico tratante, cédula profesional | Attending physician, professional license number |

Abbreviations follow the Spanish order, so TA (tensión arterial) is BP in English. Lab values keep their units and reference ranges exactly as printed, and the decimal comma in a Spanish report stays a decimal, never a thousands separator.

## Vaccination records for the I-693 medical exam

This is the most common reason people translate Spanish records. The I-693 instructions tell applicants to bring any medical records, including vaccination records, to the first appointment with the civil surgeon[2]. CDC's instructions to civil surgeons put the translation on the applicant, who provides reliable English translations of all records[1].

Dates matter more than anything else on a cartilla. Only doses whose records include the month, day and year count[1]. A Mexican booklet often has handwritten dates and clinic stamps in small boxes. LoreAI reads the handwriting and the stamps, and the dates stay as written in the English file.

## Spanish medical records for USCIS and US doctors

Medical records filed with USCIS, for example to support a waiver or a disability exception, need a full English translation that the translator certifies as complete and accurate, plus a certification that they are competent to translate[3]. The I-693 instructions repeat this and ask for the translator's signature, printed name, signature date and contact information[2].

A US doctor or insurer usually just needs to read the record. An English Word file with the same tables and headings as the original lets them find the diagnosis and the lab values without a phone call to the clinic abroad.

## How to translate Spanish medical records with LoreAI

1. **Scan or photograph the records.** Every page of the expediente, both sides of the vaccination card, and any lab printouts.
2. **Upload them and choose English.** LoreAI detects Spanish on its own and reads typed text, handwriting and stamps.
3. **Download the Word file.** Lab tables stay tables, with values and units in their columns, and dates stay as written.
4. **Add a certification when the receiver needs one.** A bilingual person reviews the file and signs. The [certificate of translation template](https://www.loreai.org/certificate-of-translation-template) has the wording.

LoreAI is not a certified translation service. Your first document is free, up to 3 pages, and Basic covers up to 30 pages per document.

## Questions people ask

### How do you say medical records in Spanish?

Expediente clínico in Mexico, historia clínica in Spain and most of Latin America. A single report is an informe médico.

### Do I need a certified translation of my vaccination card for the civil surgeon?

CDC asks for reliable English translations of all records, provided by the applicant[1]. Documents filed with USCIS need the translator's certification[3].

### Can LoreAI read a handwritten cartilla de vacunación?

Yes. LoreAI reads handwriting and stamps and returns the English text in a Word file with the dates as written.

### What is cartilla de vacunación in English?

Vaccination booklet or immunization record. Mexico's version is the Cartilla Nacional de Salud.

## Sources

1. [CDC: Vaccination technical instructions for civil surgeons](https://www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/vaccination.html), accessed November 9, 2026
2. [USCIS: Instructions for Form I-693, Report of Immigration Medical Examination and Vaccination Record (PDF)](https://www.uscis.gov/sites/default/files/document/forms/i-693instr.pdf), accessed November 9, 2026
3. [8 CFR 103.2(b)(3), Translations, Electronic Code of Federal Regulations](https://www.ecfr.gov/current/title-8/chapter-I/subchapter-B/part-103/subpart-A/section-103.2), accessed November 9, 2026

By Matt Mountain · Updated November 9, 2026