Patient record: what it contains and who can view it

Patient records contain all of the documents and notes that doctors have in relation to their patients. All relevant medical measures and their results must be documented in the patient record – for example the treatment and progression of an illness. Doctor’s letters and examination results must also be recorded in patient records. 

What are the benefits of a patient record?

The careful documentation provides greater certainty: All important information such as allergies to medication, pre-existing conditions and current medication is collated in the record and easy to find. The rapid access to information about previous diagnoses, medication and treatments makes it easier for doctors to take medical decisions and prevents unnecessary duplicate examinations. Doctors are also able to prove that you have been treated in accordance with medical standards. 

The patient record furthermore creates transparency for patients: You can view your patient record and track all treatment steps. This enables you to make better decisions about your medical treatment.

The record must be retained for at least ten years after treatment has ended.

Aside from the staff at your family doctor’s practice, no-one can read your patient record without your consent. All information about medical or psychotherapeutic treatment is subject to doctor-patient confidentiality. However, the doctors treating you may discuss your treatment with each other without your explicit consent if they assume that you would agree to this. 

Doctors are legally obliged to carefully protect patient data. This naturally also applies to data stored in electronic format. Medical practices must be able to prove that they are protecting the data of all patients, staff and other people who provide or process personal data. 

Can I obtain a copy of my patient record?

Insured persons are entitled to look at their entire patient record and can request copies of it.

In accordance with the German Civil Code, medical practices must immediately provide patients with a copy of their patient record on request. Where patient records are kept in electronic format, the copies can also be provided on a data carrier. The first copy of the patient record is free of charge. Patients must bear the costs of any additional copies. Doctors do not have to hand the original record over to be taken away.

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: identified illnesses
• tests and findings: for example, ultrasound or x-ray scans, 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 from other medical practitioners

Doctors can keep patient records in hard copy (on index cards) or electronic format. Any subsequent modifications or additions to the record must be clearly indicated. The original content must also remain visible. If the patient record is electronic, the doctor must use tamper-proof software.

If medical malpractice is suspected, the patient record can be important evidence. Medical reports within the scope of compensation claims are also based on the patient record. If doctors have not or have insufficiently documented when, how or whether a measure was performed, they must evidence this in other ways. If unable to do this, the measure shall be regarded as not having been performed in the event of a legal dispute.