§630f BGB in Practice: What the Digital Treatment Record Must Be Able to Do

The letter from a law firm reaches the hospital on a Tuesday, copied to the department. It requests the complete treatment documentation of a patient who was on the ward in the autumn of 2019. Seven years later, the record is expected to tell what happened back then: who examined when, which finding was available at what point, why the antibiotics were switched on day three.

The attending from those days now works at another hospital. The nurse who documented that night has retired. What remains is what is in the system — and the question of whether the system itself holds up as a witness.

The norm that governs this moment is §630f BGB — the provision of the German Civil Code governing treatment documentation. It is short, and each of its three paragraphs has a practical point for everyday hospital work.

Paragraph 1: document promptly — and keep every change recognizable

The treatment record is to be kept "in direct temporal connection with the treatment" [1]. What that means in hours is stated neither by the statute nor by any decision of Germany's highest courts — a fixed deadline does not exist. Whoever documents at the end of the shift can probably still rely on the direct connection; whoever routinely pushes the night shift's documentation to the day after next visibly departs from the wording. More precision than that the legal situation currently does not offer, and it would be unserious to claim it.

The second sentence is drawn more sharply: corrections and changes to entries are permissible only if, alongside the original content, it remains recognizable when they were made. Sentence 3 clarifies that this must also be ensured for electronically kept records [1]. On paper, a correction leaves traces by itself — what is crossed out stays legible. In software, the old state vanishes without a trace unless the system is expressly built otherwise.

What the BGH made of it

In 2021, the BGH — Germany's Federal Court of Justice — drew the consequence for electronic systems: electronic documentation that, contrary to §630f (1) sentences 2 and 3 BGB, does not make subsequent changes recognizable carries no positive evidentiary weight that the documented measure actually took place (judgment of 27 April 2021 – VI ZR 84/19) [2]. Translated: if such a record says "consent discussion held," the court may believe the entry — but it does not have to, and it will weigh it critically. The hospital's evidentiary position thus hangs on a software property that appears in hardly any product demo: the change history.

Important for context: the BGH does not thereby require any particular technology, and a record that is not change-proof is not a treatment error either. It is something quieter — a record whose entries weigh less in a dispute. A hospital notices that only at the moment it depends on them.

Professional law demands something flanking: §10 of the Musterberufsordnung — the model professional code for physicians in Germany — requires "special safeguarding and protective measures" for records kept on electronic media, to prevent alteration, destruction and unlawful use [3]. What is binding are the professional codes of the respective state chambers of physicians.

Paragraph 2: what belongs in it — expressly including the physician letter

To be recorded is everything that is, from a professional point of view, material to the current and future treatment, and its results; the statute names in particular the history, diagnoses, examinations and their results, findings, therapies and their effects, procedures, consents and consent discussions. Then comes a sentence that is overlooked in many hospitals: "Physician letters are to be included in the treatment record." [1]

The letter is thus part of the record, with all the requirements that apply to the record — including the recognizability of changes. Hospitals that keep letter drafts in dictation systems, Word folders or email inboxes until at some point a final version moves into the hospital information system have a gap at this spot: the path from draft to signed version can no longer be reconstructed later.

Paragraph 3: ten years — at least

The record is to be retained for ten years after the conclusion of treatment, "unless other retention periods exist under other provisions" [1]. Such provisions exist: §85 (2) of the Strahlenschutzgesetz, Germany's radiation protection act, requires 30 years for treatments; records of examinations of minors are to be retained until the person's 28th birthday [4].

For digital systems, this is the most uncomfortable requirement of all. 30 years outlast any realistic lifespan of a single hospital information system. An export that takes only the last version and leaves the version history behind destroys, at every migration, exactly the property that matters under the BGH line.

Five questions for any system

1. Show me the change history of a specific entry: original content, changed content, time, acting person — visible to clinical users, without admin tools.
2. What happens to this history on export and migration? Have an export shown to you and look for the version history in it.
3. Are physician letters, including their draft stages, part of the record, or do they live in a side system?
4. Does the system support prompt documentation within the workflow, or does it force the evening batch work that strains the "direct temporal connection"?
5. Who can delete entries — and what remains visible afterwards?

Whoever asks these questions in a vendor meeting quickly gets a sense of whether a manufacturer has ever read §630f.

For its own document generation, aiomics is planning the consequence of this legal situation as a design feature: §630f-proof versioning, in which every draft, every change and every sign-off is recorded with timestamp and role — making the physician's review of an AI draft provable after the fact. This pipeline is planned and not released; live today is the basic generation of document drafts. What should happen between draft and signature is described in the article on the defensible physician letter pipeline (in German); how documentation gaps play out in court, in the article on the burden of proof in documentation deficiencies (in German).

If you want to walk through the change recognizability of your current systems soberly, write to us — even without evaluating aiomics. Ongoing analysis of this kind comes in our weekly briefing Visite (German; English edition Grand Rounds is in preparation).

Sources

1. §630f BGB — Dokumentation der Behandlung. https://www.gesetze-im-internet.de/bgb/__630f.html
2. BGH, Urteil vom 27.04.2021 – VI ZR 84/19. https://dejure.org/dienste/vernetzung/rechtsprechung?Gericht=BGH&Datum=27.04.2021&Aktenzeichen=VI+ZR+84/19
3. §10 (Muster-)Berufsordnung für die in Deutschland tätigen Ärztinnen und Ärzte (MBO-Ä) — Dokumentationspflichten.
4. §85 Abs. 2 Strahlenschutzgesetz (StrlSchG); Landesärztekammer Hessen, Merkblatt „Aufbewahrungsfristen von Patientenunterlagen“. https://www.laekh.de/fileadmin/user_upload/Aerzte/Rund_ums_Recht/Publikationen_und_Merkblaetter/Aufbewahrungsfristen_Patientenunterlagen.pdf

Sources accessed in July 2026.