What must a historia clínica contain under Ley 41/2002?

Ley 41/2002 requires each centre to keep a historia clínica for every patient that identifies the professionals who took part, holds the contenido mínimo the law lists, and is kept at least five years from each discharge. Cataluña adds one record per patient, every change logged with its author, and 15 years for key documents.

What the law requires

The historia clínica is the set of documents on each patient's care processes, with the identification of the doctors and other professionals who took part, and every centre archives its records on whatever support it uses, securing their conservation and recovery.¹ The administrations must secure the authenticity of the content and of the changes made to it.¹ Its contenido mínimo runs from the clinical and statistical sheet to the anamnesis and physical examination, the evolución, medical orders, interconsultation, test reports, consentimiento informado and the discharge report, and several items apply only to hospital admissions.¹

Its main purpose is adequate care, so the professionals who diagnose or treat the patient have access to it, administrative staff see only the data their work needs, and anyone who reads it is bound by secrecy.¹ Centres keep clinical documentation at least five years from the alta of each proceso asistencial, the patient may see their record and obtain a copy, professionals may withhold their anotaciones subjetivas, and every centre must keep its records in active and diligent custody.¹

The stricter Catalan rules

Catalan law lets the record sit on paper, audiovisual or electronic support, provided its authenticity and later reproduction are secured, and requires every change to be recorded with the professional who made it identified.² It keeps consent forms, discharge reports, surgical and birth records, anaesthesia data and test reports at least 15 years from discharge, and lets other documentation be destroyed after five.²

1. One record per patient. Every consultation, test, consent and letter filed to the same historia clínica.
2. An author on every entry. Each note signed by the professional who wrote it, with the date and time.
3. Changes that stay visible. A correction is a new entry under a name, and the original stays readable.
4. Access by role. Clinicians who treat the patient see the clinical record, administrative staff see what their work needs.
5. Retention by document. Five years from discharge at least, and 15 years for key documents in Cataluña.
6. A route for access requests. Who handles a patient's request for a copy, and how fast.

1. Centre ______ Responsible for custody ______
2. Support used ______
3. How authors are identified ______
4. How changes are recorded ______
5. Retention period ______ From ______
6. Access requests handled by ______ Within ______
7. Last reviewed on ______

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Questions

Can our historia clínica be fully electronic?

Yes, Ley 41/2002 allows any support that secures conservation and recovery, and Catalan law allows electronic records that keep authenticity and log every change.

How long do we keep it?

At least five years from the alta of each proceso asistencial, and in Cataluña at least 15 years for consent forms, discharge reports, surgical records and test reports.

Can a patient see the clinician's private notes?

The patient may access the record and obtain a copy, and professionals may withhold their anotaciones subjetivas from that access.

Sources

1. 1Boletín Oficial del Estado, 2023Ley 41/2002, de 14 de noviembre, básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica, texto consolidadoRead source
2. 2Boletín Oficial del Estado, 2025Ley 21/2000, de 29 de diciembre, sobre los derechos de información concernientes a la salud y la autonomía del paciente, y la documentación clínica (Cataluña), texto consolidadoRead source

Written by the wai team from Health authorities of the Comunidad de Madrid and Cataluña guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither the Comunidad de Madrid's Consejería de Sanidad nor the Generalitat's Departament de Salut endorses wai or any software.