medical records
noun · Patientenakte
The Patientenakte is not the clinic’s private file: § 630f BGB requires the treating party to document the treatment in immediate connection with it, corrections must remain visible alongside the original entry, and § 630g BGB gives the patient a right to inspect it without having to give reasons. What is missing from the file counts against the treating side in a dispute.
Which translation, when
Why
Medical records are the Patientenakte, and the German provisions treat the file as a shared instrument rather than as the clinic’s internal paperwork. Section 630f BGB obliges the treating party to keep a file, in paper or electronic form, and to record in it, in immediate temporal connection with the treatment, all measures and their results that are essential from a professional point of view, which the provision spells out as anamnesis, diagnoses, examinations and their results, findings, therapies and their effects, interventions and their effects, consents and explanations, with doctors’ letters to be included. Corrections are permitted but must be made transparently: the original content has to remain recognisable and the change must be datable, which is why overwritten electronic records raise immediate suspicion. Section 630g BGB then turns the file towards the patient, who may inspect it in full, without delay and without giving any reason; inspection can be refused only where significant therapeutic grounds or substantial rights of third parties stand against it, and the patient may take copies against reimbursement of costs. After a death the right passes to heirs pursuing pecuniary interests and to close relatives pursuing immaterial ones, unless the deceased objected. The reason the file dominates German medical litigation is evidential: what should have been documented and does not appear is presumed not to have been done, so a gap in the record hurts the treating side rather than the patient. The general architecture of proof, including the shift of the burden after a grave treatment error, is held by the burden of proof entry, and a translation should not reproduce it here.
Typical mistakes
- Documentation must be made in immediate temporal connection with the treatment and corrections must leave the original recognisable, § 630f BGB, so a file reconstructed later is not compliant.
- Inspection under § 630g BGB needs no reasons, so wording that makes access dependent on the clinic’s agreement misstates the right.
- A measure that should have been documented and is missing is presumed not to have happened, so gaps count against the treating side.
What matters
Handling a German patient’s request for records: the reply should use Patientenakte, treat inspection as a right exercisable without reasons, and offer copies against costs rather than asking why the file is wanted.
What the machine misses
Automatic output turns medical records into medizinische Aufzeichnungen, a phrase German law does not use, and the statutory object is the Patientenakte of § 630f BGB with the inspection right of § 630g BGB; the loose rendering also hides that the file carries evidential weight, since undocumented measures are presumed not to have taken place.
Examples
| the patient records | die Patientenakte |
| to inspect the file | Einsicht in die Akte nehmen |
| copies against reimbursement of costs | Abschriften gegen Kostenerstattung |
| the documentation duty | die Dokumentationspflicht |