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§ 630 f German Civil Code (BGB) - Documentation of the treatment

(1) For the purpose of documentation, the treating party is obliged to keep medical records in paper form or as electronic documentation in a direct temporal link with the treatment. Corrections and alterations of entries in the medical records are only permissible if, in addition to the original content, the point in time at which they were carried out remains recognisable. This is also to be ensured for medical records that are kept electronically.

(2) The treating party is obliged to record all measures in the medical records which are relevant in medical terms for the current and future treatment and its results, in particular the establishment of the medical history, diagnoses, examinations, results of examinations, findings, therapies and their effects, procedures and their impact, consent and information. Physicians’ letters are to be included in the medical records.

(3) The treating party must keep the medical records for a period of ten years after the conclusion of the treatment unless other periods for their retention exist in accordance with other provisions.

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