Getting your medical records and using the digital health folder

Key rules

• Where to ask: Request your records from the centre where you were treated, in writing, showing your photo ID.
• First copy: Your first copy is free; later copies may carry a reasonable fee.
• Doctors' notes: Doctors can keep their subjective notes and other people's data out of your copy.
• Regions differ: Procedures, fees, extra retention periods and digital folders vary by region, so confirm with your regional health service.

You ask the centre where you were treated

You can request your clinical history, or copies of it, from the patient-service office (atención al paciente) or the medical records office (archivo de historias clínicas) of the hospital or health centre that treated you. Each centre handles its own records, so go to the one that holds them.

Ask in writing, on the centre's form or in a letter. Many places also accept the request through the regional health portal or its electronic office. Show your photo ID when you ask. The documents list below covers what to bring.

Choose how you want to receive the records: paper copy, CD or USB for images, or electronic download. Some regions let you collect them in person. Procedures differ by region and centre, so ask the office what applies.

If someone else asks for you, they need your written authorisation and copies of both IDs.

What you can and cannot see

You have the right to see your clinical history and to get copies of the data in it. This applies in public and private care.

Two things can be held back:

• Data about other people that was given to your doctors in the interest of your treatment.
• Doctors' subjective notes, meaning their personal impressions and judgments.

Relatives of someone who has died can ask for the records only if the person did not forbid it. They do not get the subjective notes or third-party data.

Cost

Your first copy is free. For further copies, or for clearly excessive requests, the centre may charge a reasonable administrative fee. Some regions publish price lists, for example per page or for imaging CDs. Many give the first copy or digital copies free. Ask the office for its fee before you order more copies.

How long it takes

The centre must answer within one month. It can extend this by two further months for complex cases. Some regions set their own, often shorter, periods. The timeline below shows the steps.

How long records are kept

Centres must keep your records for at least five years from discharge. Some regions require longer. Cataluña and Galicia, for example, use 15 years from the last care episode. If you were treated long ago, ask anyway.

The digital health folder

Most regions have their own digital health folder or personal health portal, such as La Meva Salut in Cataluña. It usually shows appointments, prescriptions, reports, test results and vaccinations. You log in with Cl@ve, an electronic certificate or DNIe. Some regions also allow a regional username. What you see depends on your region.

There are also national tools, Carpeta Ciudadana and Mi Carpeta Salud, which give a view of data held by the regions. Mi Carpeta Salud is still being developed, so check its current status with the Ministry of Health.

What other regions can see

If you move or fall ill in another region, doctors there can consult your key data through the national system, the HCDSNS. It shares:

• your patient summary
• electronic prescription and dispensing data
• clinical reports (emergency, discharge, primary care, consultation)
• laboratory and imaging results and reports

Only professionals involved in your care can look. You can see who accessed your data and ask to restrict or hide documents. Ask your regional health service how to do this.

Timeline and deadlines

• Hand in your request to the centre: when you want your records

• Wait for the centre's answer: within one month of your request

• Expect a longer wait for complex cases: two further months on top of the first month

Documents you need

• Photo ID: your DNI, NIE or passport, shown to the records office when you make the request.

• Written request: the centre's own form or a free-text letter, handed in to the patient-service or medical records office.

• Written authorisation, if someone else asks for you: it must come with copies of both your ID and your representative's ID.

• Cl@ve or an electronic certificate or DNIe: needed to log in to your regional digital health folder.

Checklist

• Ask for your clinical history or copies in writing, on the centre's form or in a letter.

• Show your DNI, NIE or passport when you make the request.

Frequently asked questions

Can I read the doctor's own notes in my clinical history?

Yes, you can see and get copies of your clinical history, but not the doctor's subjective notes. Professionals can keep their personal impressions and judgments out of your access. Data about other people given for your treatment is also kept back.

Is the first copy of my clinical history free?

Yes, the first copy of your data is free, but the centre can charge a reasonable fee for further copies or clearly excessive requests.

Can a relative ask for the records of someone who has died?

Yes, relatives can ask, but only if the patient did not forbid it while alive. They still cannot see the deceased person's subjective notes or other people's data.

What health data can doctors in another region see about me?

Doctors involved in your care in another region can see your key data, such as your patient summary, electronic prescriptions, clinical reports, and lab and imaging results.