Patient record

Doctors must keep a patient record for every patient. This must document all the main medical measures and their outcomes – for example, notes on the patient’s history, the circumstances and progression of illnesses, plus findings, such as the results of tests, diagnoses, treatments and prescriptions.

The patient record enables all the information of any importance to you as the patient to be noted down and referred to later. Not only does this ensure greater reliability in terms of treatments, but it also shows that treatment has been provided correctly. The patient record can make it easier for doctors and other health institutions to share information. But it also creates more transparency for patients: because they can view their patient record whenever they wish.

The doctor can either keep the patient record in paper form or as an electronic document. It must be retained for at least ten years after treatment has ended. The document obligation for the patient record is regulated in § 630f BGB (German Civil Code).

As the patient, you have the legal right to look at your complete patient record at the medical practice. The legal basis for this is laid down in the German Civil Code (BGB § 630g). The doctor must grant your wish to view it without delay, i.e. as quickly as possible. It can take a few days before the practice can make it happen.

Doctors do not need to hand the original record over to be taken away. But insured persons are entitled to look at their entire patient record, and they can ask for copies of it. Where patient records are kept in electronic form, the copies can also be provided on media. The insured persons bear the costs of copies themselves.

When a patient dies, the family members or heirs essentially have the same right to see the record, unless the deceased person was explicitly or presumably against this.

Doctors must record all the circumstances that are important for the treatment in the patient record – in a timely manner and comprehensively. These include the following:

• the medical history (anamnesis): known symptoms, the mental state, social worries, illness in the family
• diagnoses: illnesses or allergies identified
• notes on circumstances and the progression of treatments
• tests and their results and findings: for example, from ultrasound or X-ray tests, blood tests, or heart examinations (ECG)
• therapies and their effects: prescribed treatments and medications, but also the effects and possible side-effects
• interventions and their effects: for example, reports on operations and anesthesia protocols
• the patient’s declarations and consents
• doctors’ letters, i.e. communications with other medical practitioners

Doctors can either keep the patient records in paper form, for example on index cards, or electronically. Any changes or additions to the patient record made retrospectively must be annotated with the date of the change. The original content must also remain visible. If the patient record is electronic, the doctor must use tamper-proof software.

If a treatment error is suspected, the patient record can be important evidence. In cases where documentation obligations are not complied with or treatment documents are lost, the law explicitly states that the patient’s burden of proof should be less than the norm. So in a case where the documentation of a measure that should be recorded for medical reasons is missing, poor or incomplete, the doctor must provide evidence that he or she took that measure.