The record has two readers: what has to go into the documentation — and who may read it

A lot is said about the documentation duty, and mostly the same thing: it costs time, it comes after the session, it piles up. The provision next to it is rarely talked about, although it changes the way one documents.

The duty is laid down in § 630f BGB (German Civil Code). The patient’s right to inspect, in principle, the complete record is laid down in § 630g BGB. The two belong together, and anyone who thinks them through together writes different notes afterwards.

What goes in

Under § 630f paragraph 2, all measures that are essential from a professional point of view and their results must be recorded: medical history, diagnoses, examinations and their results, findings, therapies and their effects, interventions and their effects, consents and the information given to the patient. Doctors’ letters are to be included.

The word essential carries more than it seems. The law does not require a transcript, nor completeness in the sense of leaving no gaps — it requires what is professionally essential, measured against the current and the future treatment. Anyone who writes everything down does not fulfil the duty better; they only make the record less usable.

It is kept in direct temporal connection with the treatment. Paper or electronic — that is left open.

The timing counts too

The provision requires not only a content, but a point in time: in direct temporal connection with the treatment. The direct temporal connection is part of the documentation duty itself. It helps to secure the reliability and traceability of the records — what was set down promptly is less prone to inaccuracies than a reconstruction from memory.

The law names no limit in hours or days; “direct” is a standard, not a deadline. In practice, this means neither “in the same minute” nor “some time at the weekend, when twelve sessions have piled up”. The greater the gap, the more one documents the memory of the session instead of the session — and the more likely one has to explain that if in doubt.

The way out that some find obvious is blocked by the amendment rule: entries inserted or corrected afterwards must remain recognisable as such. A record that was smoothed out afterwards without showing it has not been kept properly.

This makes the 51st minute not a question of self-organisation, but one of record-keeping. Anyone who keeps putting it off does not only postpone work, but weakens the value of their own records — and someone else assesses that later.

The amendment rule — and what it says about your software

A paragraph that is easily overlooked and has consequences in practice: corrections and changes are only permissible if it remains recognisable, alongside the original content, when they were made (§ 630f paragraph 1). This applies expressly to electronically kept records as well.

This makes it not only a requirement on your diligence, but also on your tool. What matters is not the individual input field, but whether the system as a whole preserves the original content and the time of the change in a traceable way — an immutable change or version log can achieve this just as well as a visible history. What is not sufficient: a system in which the earlier state can no longer be reconstructed anywhere after it has been overwritten.

This is a question one can ask a provider before signing a contract.

Ten years — from when?

The treatment record must be retained for ten years after the end of treatment, unless other retention periods exist under other provisions (§ 630f paragraph 3 BGB). The wording of the law speaks of other, not of longer periods.

In addition, there is a separate retention obligation under professional law. The professional codes of the chambers of psychotherapists regularly also provide for ten years, unless a longer period follows from statutory provisions. What is decisive is the professional code of your chamber in force at the time.

The start of the period is the point where it becomes blurred. The point of reference is the end of treatment. It can coincide with the last session, but does not have to: in the case of a discontinuation, a longer break or a later resumption, determining the start of the period is a question of the individual case. Errors work in both directions here: deleting too early as well as retaining beyond any justification.

The record has two readers

This is the part that changes the way of working.

The patient can demand to inspect, without undue delay, the complete record concerning them (§ 630g paragraph 1). Inspection may only be refused by way of exception — wholly or in part — if substantial therapeutic reasons or other substantial rights of third parties stand in the way (§ 630g paragraph 2), and the refusal must be justified.

And now the point at which a widespread assumption turns out to be wrong: personal notes and subjective perceptions of the treating practitioner that are documented in the treatment record are, in principle, also subject to the right of inspection. This is what the explanatory memorandum to the Patients’ Rights Act says: records of personal impressions or subjective perceptions of the treating practitioner concerning the person of the patient are in principle to be disclosed; when weighed against the patient’s right of personality, a justified interest in non-disclosure does not, as a rule, exist. The memorandum adds, however, that here too it depends on the circumstances of the individual case (Bundestag printed paper BT-Drucksache 17/10488, p. 27). The information sheet of the Berlin Chamber of Psychotherapists sums this up to the effect that the treating practitioner is, in this respect, not a “third party” within the meaning of the exception.

It thus remains conceivable that personality rights of the treating practitioner may, in an individual case, support a partial refusal after all — the explanatory memorandum does not rule this out, it merely considers it not to be given as a rule. A general exception in favour of one’s own personality rights, settled by the highest courts, is however not apparent for § 630g BGB. Anyone who relies on it is relying on the individual case.

When is a therapeutic reason “substantial”?

Everyone asks this question, and it has a standard that is rarely quoted. Substantial therapeutic reasons are to be assumed if the inspection gives rise to the risk of serious harm, including self-harm, in particular a risk of suicide. A specific risk must be concretely feared.

Expressly not sufficient is that the patient merely could not reasonably be expected to take note of the content (Federal Court of Justice, BGHZ 106, 146). In principle, the patient decides for themselves what they wish to expect of themselves.

Two further rules narrow the room for manoeuvre. Refusal is the last resort and only permissible in special individual cases; beforehand, it must always be checked whether an accompanied inspection — together with another or a subsequent practitioner — suffices as a less severe means. And in case of doubt, the patient’s interest in information takes precedence (BT-Drucksache 17/10488, pp. 26 f.).

Where third parties come in

Information about the personality of third parties is in turn worthy of protection and can support a refusal if their interest in protection prevails in the specific weighing. In practice, this arises in two places: when parents of minor patients have disclosed personal information — and in group treatment, where the personality rights of the other group members have to be taken into account.

For a minor who does not yet have the capacity for insight, the right of inspection is in principle exercised by the persons with parental responsibility. If parental responsibility is joint, a joint decision is in principle required; powers of representation and situations of conflict may require a separate examination.

And when the record is sent

Instead of inspection, the patient can demand that copies be sent — including electronic copies. Since 6 February 2026, § 630g paragraph 1 sentence 4 BGB expressly clarifies: the first copy is provided free of charge. The change goes back to the Act of 3 February 2026 (Federal Law Gazette, BGBl. 2026 I No. 28) and implements a judgment of the Court of Justice of the European Union of 26 October 2023 (C-307/22). The same Act restructured the provision — the grounds for refusal have since stood in a paragraph 2 of their own — and replaced the term Patientenakte (patient record) with Behandlungsakte (treatment record).

If the record is sent electronically, the transmission route must correspond to the high need for protection of health data. An unencrypted ordinary email is regularly not appropriate for this. Article 32 GDPR is, however, worded in a risk-based way: what is required is a procedure that corresponds to the need for protection — suitable end-to-end encryption or a comparably secured route.

What follows from this — and what expressly does not

If personal impressions are in principle open to inspection, then every note has two readers: you yourself, for the treatment — and possibly the patient.

It does not follow from this that one should document less. That would be the convenient and the wrong reading. The duty under § 630f remains unchanged, and a thin record is the weaker position in a dispute. If the documentation of a medically required essential measure and its result is missing, a statutory presumption of evidence may even follow from this: under § 630h paragraph 3 BGB, it is then presumed that the measure was not taken.

What does follow is to write differently. Observation instead of judgement. What was said and what was done, instead of what one thought of it. Professional assessment marked as such, not disguised as fact. This is not a matter of consideration, but better documentation — it also stands up to one’s own rereading in two years’ time.

The most useful test sentence for daily work is therefore: Could I show this to the patient and explain it? If yes, the note is probably good. If no, the question is not how to hide it, but why it is worded that way.

After death

Heirs can demand inspection in order to safeguard financial interests, the closest relatives in order to safeguard non-material interests. For them, however, paragraph 3 expressly contains an obligation to reimburse costs; the free first copy under paragraph 1 therefore does not apply to them. The claim lapses if it contradicts the express or presumed wishes of the patient (§ 630g paragraph 3). This too is a reason to record, during the patient’s lifetime, what the patient has said about it.

About the status of this text

This article reflects the status as of 27 August 2026. It offers orientation, not legal advice, and it does not assess any individual case — in particular not the question of whether a substantial therapeutic reason exists in a specific treatment. What is decisive are the versions in force of the provisions named and the professional code of your competent state chamber of psychotherapists — statutory rules of the chamber on the basis of state law. This is a translation; the German version („Die Akte hat zwei Leser“) is authoritative.

A note on our own behalf: this text comes from Psymira, a provider of documentation software for psychotherapy practices. The section on the amendment rule sets out a requirement that applies to every system — including ours. We consider it the most useful point to check in a conversation with a provider, regardless of which provider one chooses.