What must a German patient file show under § 630f BGB?

§ 630f BGB requires the treating doctor to keep a patient file, on paper or electronic, made in direct connection with the treatment, where any correction leaves the original content and the date of the change visible. The file is kept ten years after treatment ends, unless another rule sets a different period.

What the file must contain

The file records every measure relevant to current and future treatment and its result, including history, diagnoses, examinations, findings, therapies and their effects, procedures, consents and explanations, and doctors' letters go into it.¹ Corrections and changes are allowed only if the original content stays recognisable and it is clear when they were made, and this applies to electronic files too.¹

The model Berufsordnung adds the professional duty to document, ten years of retention unless the law sets longer, and special security and protection measures for electronic records, against alteration, destruction or unlawful use.² On request, the patient sees the complete file without delay and may ask for electronic copies.³

Health data and the BDSG

§ 22 BDSG allows health data to be processed for treatment by people bound by professional secrecy, and asks for measures such as logging who entered, changed or deleted data, limits on access, encryption and regular tests of those measures.⁴ A practice names a data protection officer when, as a rule, at least 20 people constantly process personal data by automated means.⁵ The QM-RL lists information security and data protection among its Grundelemente.⁶

1. Write at the time. Each entry made during or straight after the consultation, under the doctor's name.
2. Never overwrite. A correction adds to the entry and keeps the original and the date visible.
3. File every letter. Doctors' letters, results and consents go into the same file.
4. Log every access. Who read, entered or changed data, under a named account.
5. Answer access requests promptly. The patient sees the file without delay and receives copies on request.
6. Diary the retention. Ten years from the end of treatment, longer where another rule says so.

1. Date ______ Checked by ______
2. File 1, entries timed and signed ______ Corrections visible ______
3. File 2, letters filed ______ Consent recorded ______
4. File 3, access logged ______
5. Retention dates set ______
6. Gaps found ______ Owner ______ Fixed by ______

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When a doctor or practice stops

After giving up a practice, the doctor keeps the records for the retention period or ensures they pass into proper custody, and whoever holds them keeps them locked and opens them only with the patient's consent.²

Questions

How long must we keep patient files?

Ten years after treatment ends under § 630f BGB, unless another rule sets a different period.

Can we correct a wrong entry?

Yes, as long as the original content stays recognisable and the date of the change is clear, on paper or electronically.

Does the patient pay for a copy?

Under § 630g BGB the first copy is provided at no charge, and the patient may ask for electronic copies.

When do we need a data protection officer?

Under § 38 BDSG, as a rule once at least 20 people constantly process personal data by automated means.

Sources

1. 1Bundesministerium der Justiz, Gesetze im Internet, 2026§ 630f BGB, Dokumentation der BehandlungRead source
2. 2Bundesärztekammer, 2026(Muster-)Berufsordnung für die in Deutschland tätigen Ärztinnen und Ärzte, MBO-Ä 1997, in der Fassung des 130. Deutschen Ärztetages vom 13. Mai 2026Read source
3. 3Bundesministerium der Justiz, Gesetze im Internet, 2026§ 630g BGB, Einsichtnahme in die PatientenakteRead source
4. 4Bundesministerium der Justiz, Gesetze im Internet, 2026§ 22 BDSG, Verarbeitung besonderer Kategorien personenbezogener DatenRead source
5. 5Bundesministerium der Justiz, Gesetze im Internet, 2026§ 38 BDSG, Datenschutzbeauftragte nichtöffentlicher StellenRead source
6. 6Gemeinsamer Bundesausschuss, 2026Richtlinie über grundsätzliche Anforderungen an ein einrichtungsinternes Qualitätsmanagement (QM-RL), Volltext, BAnz AT 19.08.2026 B4Read source

Written by the wai team from Gemeinsamer Bundesausschuss, the Kassenärztliche Vereinigungen and the Länder guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither the G-BA, any KV nor any Land authority endorses wai or any software.