Documentation duty in the medical practice: what § 630f BGB requires, how long the record is kept, and what applies to gaps
Under § 630f BGB (German Civil Code, documentation of treatment), treating practitioners must keep a patient record in immediate temporal connection with the treatment, record in it all measures and results that are material from a professional standpoint, and retain the record for ten years after the treatment ends as a rule. If a material measure is missing from the record, § 630h BGB presumes that it was not carried out.
Reviewed editorially against product behaviour and the stated primary sources; not individual medical or legal advice.
This overview is general information, not legal advice. Which content, deadlines and forms apply to a specific practice depends on the specialty, professional code and other rules, and should be clarified with the practice's legal advisers.
What § 630f BGB requires
Paragraph 1 obliges treating practitioners to keep a patient record, on paper or electronically, in immediate temporal connection with the treatment for documentation purposes. Corrections and changes are only permitted if the original content remains identifiable and the time of the change is recorded; for electronic records, the software must ensure this.
Paragraph 2 sets out the content: all measures and their results that are material from a professional standpoint, such as history-taking, examinations and their results, findings, treatments and their effects, procedures, consents and information given. Referral and discharge letters must be included in the record. The full list is set out in the statute.
How long the patient record must be kept
Paragraph 3 sets ten years after the treatment ends, unless other rules provide for different retention periods. The professional codes of the regional medical associations and individual specialty laws provide for longer periods for certain kinds of documents.
For the practice this means a schedule of deadlines by document type, not one blanket deadline for everything. Audio recordings, transcripts and drafts are not part of the record unless the practice deliberately makes them so; their retention and deletion follow the data protection concept.
What a gap in the documentation means
§ 630h paragraph 3 BGB governs the burden of proof: if a medically indicated material measure and its result were not recorded, or the record was not retained, it is presumed that the measure was not carried out. This is not a sanction in itself, but a rule for a liability dispute; consequences under professional law follow the professional code.
- The presumption can be rebutted, but the practice then carries the burden of presenting evidence.
- Additions are permitted if they are identifiable as such and the time is recorded.
- A later reconstructed record therefore does not replace a prompt one.
Documenting promptly without typing during the consultation
A documentation-support application shifts the work, it does not take it away: a transcript is produced from the recorded consultation, and a structured draft from the transcript. The draft is not yet documentation. Only once the physician has reviewed, corrected and carried it into the practice software does the content become part of the record.
Because carrying it forward can happen right after the appointment, the process fits the requirement of immediate temporal connection. An interrupted consultation remains one session, so the draft reflects the whole appointment rather than only its last part.
- The transcript is a working state, not the record.
- The draft reproduces what was said; the clinical assessment remains the physician's task.
- What belongs in the record is decided by the treating physician when adopting the draft.
Electronic record: keeping changes traceable
For electronic patient records, § 630f paragraph 1 BGB requires that later changes remain identifiable. In practice that means practice software with a change history, and a workflow in which the draft is edited before it is carried forward rather than rewriting the record afterwards.
It should be evident from the record who carried forward what, and when. A draft that is reviewed outside the practice software and then inserted satisfies this, as long as the practice software records the time it was carried forward.
Frequently asked questions
How long must a doctor keep the patient record?
Under § 630f paragraph 3 BGB, ten years after the treatment ends, unless other rules set a different period. Longer periods apply to individual document types; the practice should record the applicable period per document type.
What happens if the documentation is incomplete?
§ 630h paragraph 3 BGB allows the presumption, in a liability dispute, that an undocumented material measure was not carried out. The practice can rebut this, but then carries the burden of presenting evidence.
May I add to the documentation in the evening?
§ 630f BGB requires immediate temporal connection with the treatment. An addition is permitted if it is identifiable as such and the time is recorded; the greater the gap, the more the question arises of what is still reliably remembered.
Is an AI draft already documentation within the meaning of § 630f BGB?
No. The draft reflects what was said in the consultation. Only physician review and carrying it into the patient record makes the content documentation; responsibility for that stays with the treating practitioner.
Does the documentation duty also apply to private practices?
Yes. § 630f BGB is part of the treatment contract and applies regardless of the patient's insurance status.