Patient file what it documents who may see it

Patient recordsDoctors are required to keep a patient record for each patient. As a patient, you have the right to inspect your medical record and request a copy of it. The patient file is also important in the case of treatment errors.

At a glance

– Doctors are obliged to keep a patient file for every patient. – The patient's file contains all essential medical measures and their results. – From 2021, statutory health insurers will have to provide their insured patients with an electronic patient record (ePA). – As a patient, you have the right to inspect your file and ask for a copy. – The patient's record may also play a role in treatment errors.

What is a patient file?

Doctors are obliged to keep a patient file for each patient. All essential medical measures and their results must be documented in it – for example, records of the medical history as well as the circumstances and course of illnesses, but also findings, such as results of examinations, diagnoses, treatments and prescriptions.

With the patient file, all information that is important to you as a patient can be recorded and later retraced. This not only ensures greater treatment safety, but also serves as proof of proper treatment. The patient file can facilitate the exchange between doctors. Facilitate other healthcare facilities. But it also creates more transparency for patients. patients: For they may inspect their patient file at any time.

The doctor can keep the patient file either in paper form or as an electronic document. It must be kept for at least ten years after completion of the treatment. The documentation obligation for the patient file is regulated in Section 630f of the German Civil Code (BGB).

Important to knowThe electronic patient file, which is under the control of the insured person, must be distinguished from the doctor-managed patient file. From January 2021 at the latest, statutory health insurers must offer their insureds an electronic patient record (ePA). This will allow important medical data held by different physicians or hospitals to be pooled across facilities for the first time. Patients themselves decide whether they want to use an electronic patient file, which data is stored or deleted, and who has access to it.

What information does the patient file contain??

Doctors are obliged to record in the patient file all circumstances that are important for the treatment – promptly and completely. This includes, but is not limited to, the following information:

– the medical history (anamnesis): known complaints, the psychological condition, social stress, cases of illness in the family – diagnoses: established illnesses or even allergies – records of circumstances and the course of treatments – examinations and their results or the findings: for example, ultrasound or X-ray examinations, 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, operation reports and anesthesia protocols – explanations provided and consent given by the patient – doctor's letters, i.e., messages from other physicians

How the patient record is kept?

Doctors can keep the patient file either in paper form, for example on index cards, or electronically. Subsequent changes or additions to the patient file must always be marked with the date of the change. The original content must remain recognizable. If the patient record is kept electronically, the physician must use software that is tamper-proof.

May you view your patient file?

As a patient, you have a legal right to see your complete patient file in the doctor's office. The legal basis for this is provided by the German Civil Code (Section 630g). The physician must comply with your request for access without delay, d.h. comply as soon as possible. Sometimes it can take a few days for the practice to make this possible.

Doctors do not have to hand over the original file to be taken home. However, insured persons have the right to see their complete patient file and can request copies of it. In case of electronically kept patient records, the copies can also be provided on a data carrier. The costs for the copies are borne by the insured themselves.

If a patient dies, the relatives or heirs generally have the same right to inspect the records – unless the deceased expressly or presumably did not want this to happen.

Important to know: Only in special cases can the doctor refuse to allow access to the patient file. This is the case, for example, when the doctor fears that this could cause significant damage to the patient's health. Sometimes the inspection is not allowed, for example, in the case of suicidal people. Personal rights of third parties can also be a reason – among other things, if relatives and their relationship to the patient are mentioned in the patient file. If your doctor refuses to allow access completely or restricts access to certain parts of the patient's file, reasons must be given in each case.

What role do patient records play in treatment errors?

If there is suspicion of a treatment error, the patient file can be an important piece of evidence. The law expressly stipulates that patients have the right to prove that they have violated their documentation obligations or lost their treatment documentation. Thus, if documentation of a procedure to be recorded for medical reasons is missing, inadequate or incomplete, the physician must prove that he or she performed the procedure.

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