How must a Japanese clinic write and keep the 診療録?

Under article 24 of the 医師法, a doctor writes the 診療録 without delay after every consultation, and the clinic's 管理者 keeps it for 5 years. An electronic 診療録 must stay authentic, readable and preserved, as MHLW's security guideline 第7.0版 sets out.

What the 医師法 requires

A doctor who sees a patient must write the details in the 診療録 without delay.¹ For care given at a hospital or clinic, the 管理者 keeps the 診療録 for 5 years, and for other care the doctor keeps it.¹ The 医師法 also forbids treating, or issuing a certificate or prescription, without examining the patient in person.¹ Under article 25 of the 医療法, the 保健所 may inspect the 診療録 and the clinic's books.²

Keeping it electronically

MHLW's security guideline says documents such as the 診療録 must be written as the relevant law requires, and that information stored electronically must keep its 真正性, 見読性 and 保存性, meaning it is authentic, readable and preserved.³ Where records are stored with an outside provider, the guideline asks the clinic to make sure the equipment holding them is within reach of Japanese law, to check the country where it sits and whether foreign law applies to the provider, and to explain the arrangement to patients in advance, for example by a notice in the clinic.⁴

1. Write it at once. Every consultation written up without delay, by the doctor who saw the patient.
2. Sign it. The doctor's name and the time on every entry, with any change kept visible.
3. Keep it 5 years. Under the 管理者's control, for every consultation at the clinic.
4. Keep it readable. Any entry can be found and shown on screen or on paper when asked.
5. Check where it is stored. The country of the servers, the law that applies, and the notice patients see.
6. Answer disclosure requests. A route for patients to see their record, with any fee kept reasonable.

1. Clinic ______ 管理者 ______
2. Entries written within ______ of each consultation
3. Retention 5 years from ______
4. Storage location and country ______ Patient notice posted on ______
5. Disclosure requests handled by ______ Fee ______
6. Policy reviewed on ______

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When AI drafts the note

Only a doctor may practise medicine, and the 医師法 puts the duty to write the 診療録 on the doctor who gave the care.¹ A note drafted by AI fits that when the doctor reads it, edits it and signs it under their own name, and the record keeps every change. MHLW's inspection notice reminds authorities that fees for disclosing records must be reasonable and must not discourage patients from asking.⁵

Questions

How long must a Japanese clinic keep the 診療録?

5 years under article 24 of the 医師法, kept by the clinic's 管理者 for care given at the clinic.

Can the 診療録 be kept only in electronic form?

Yes, where the record keeps its 真正性, 見読性 and 保存性 as MHLW's security guideline describes.

Who signs a note drafted by AI?

The doctor who gave the care, after reading and editing it. The 医師法 puts the duty to write the 診療録 on that doctor.

Sources

1. 1e-Gov法令検索, Digital Agency, 2026医師法 (Medical Practitioners' Act), Act No. 201 of 1948Read source
2. 2e-Gov法令検索, Digital Agency, 2026医療法 (Medical Care Act), Act No. 205 of 1948Read source
3. 3Ministry of Health, Labour and Welfare, 2026医療情報システムの安全管理に関するガイドライン 第7.0版 概説編Read source
4. 4Ministry of Health, Labour and Welfare, 2026医療情報システムの安全管理に関するガイドライン 第7.0版 企画管理編Read source
5. 5Ministry of Health, Labour and Welfare, 2025令和７年度の医療法第25条第１項の規定に基づく立入検査の実施について, 医政発0627第９号, 27 June 2025Read source

Written by the wai team from Ministry of Health, Labour and Welfare, with the prefectures and public health centres guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither MHLW nor any prefecture or public health centre endorses wai or any software.