Can a doctor understand the handwriting of other doctors?

Request patient record: Doctors make it difficult for patients

Published on August 11, 2015
When patients request their medical records, they show up Practices rarely cooperative. This was the conclusion reached by Stiftung Warentest (edition 08/2015) in the course of a random sample. The right to inspect the files is enshrined in law and does not have to be an expression of mistrust. Often times, patients can no longer remembering individual treatments or want to inform other doctors about examinations that have taken place. Some people also value their To be able to assess the state of health yourself and talking to the doctor retrospectively work up and understand.

Requesting a patient record is a right

Still at least ten years after treatment a patient file can be requested. This is what the Patient Rights Act prescribes. This is the period for which the treating physicians are obliged to keep the documentation. According to Section 630g of the German Civil Code, doctors must treat their patients immediate access to the file grant and on I also want copies issue. Whoever makes use of this right has to do it incurred costs such as paper, data media or shipping, however, carry it yourself.

The right to inspect files does not only exist for medical treatment, but also also for psychotherapies. However, this only applies to the objective information that is subject to documentation. The client has no right to view the personal notes made by the therapist during the session.


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Test shows: practices are reluctant to publish patient files

Stiftung Warentest wanted to find out what people can actually expect when they request their patient files based on a random examination. To do this, the consumer organization sent three test persons each to family doctors, gynecologists, ophthalmologists and dentists. It is true that the results cannot simply be generalized. Within the sample it is about the Perception of the medical documentation and information obligation, however, extremely poor.

Only in two out of twelve cases the file was willingly released. In six practices, however, the staff initially asked for the reasons, and in four cases the employees even reacted dismissively. Of the twelve files requested were seven almost empty or at least very sketchy. Three of them were due to the copy quality difficult to read, even the manuscripts were difficult to decipher. The testers did not have to pay anything or a maximum of 50 cents for the required patient files. Only one doctor asked for EUR 14.40.

Editor's tip: What does a complete patient record contain?

A patient record must document all contact between doctor and patient. According to § 630g (BGB) this includes “anamnesis, diagnoses, examinations, test results, findings, therapies and their effects, interventions and their effects, consent and information”.

What to consider when requesting the patient file

When patients request their patient files, the caregivers must hand them over. However, doctors and psychotherapists are then allowed to use the document withhold if the information could be proven to be harmful to the patient or when confidential information about third parties or about the treating person themselves need to be protected. Patients can request their files in person, over the phone or in writing, but must be able to prove their identity for data protection reasons. You do not have to give reasons for the request. If the practice or clinic does not hesitate to ask, "For my personal documents."

Those who are denied information should persist and the Repeat the request in writing. Stiftung Warentest provides a sample letter for this. If this attempt remains unsuccessful, the patient can opt out complain to a medical association or seek advice from the Independent Patient Advisory Service on further options.