Patientenakte

A Patientenakte, or patient file, is the record that documents the health information of an individual. It can be maintained as a paper file or in a digital form and is created by healthcare providers, sometimes complemented by information supplied by the patient. The purpose is to support continuity of care, inform clinical decisions, and provide a legal record of diagnoses, treatments, and outcomes.

Contents typically include identifying data, medical history, current and past diagnoses, medications and allergies, immunizations, laboratory results, imaging reports, treatment plans, notes from consultations, and forms related to consent and advance directives. In many health systems, an electronic version known as the electronic patient record (Elektronische Patientenakte, ePA) exists to consolidate data from multiple providers, with patient consent guiding access and sharing. Interoperability efforts rely on standard formats and protocols to enable information exchange across different systems.

Access, rights, and privacy are governed by data protection and healthcare laws. Patients generally have the right to view their records, request corrections, and exert control over who may access their data. Data controllers and processors must implement security measures, limit access on a need-to-know basis, and retain records according to statutory requirements. Data portability and the right to information about data processing are also relevant under applicable regulations, such as the GDPR, with national adaptations in health care practice.

Benefits include improved safety and coordination of care, reduced duplication of tests, and support for emergency treatment. Challenges involve ensuring data accuracy, protecting privacy, obtaining informed consent for sharing, and financing digital infrastructure. Germany and other countries have pursued electronic systems like the ePA as part of broader digital health and patient empowerment efforts.