Understanding a Spanish medical report or discharge letter (informe)

Terms used

• Informe de alta — The informe de alta is the report a hospital gives you when you are discharged, summarising your stay, diagnosis and treatment.
• Historia clínica — The historia clínica is your full medical record, which you have the right to see and copy.
• Analítica — The analítica is a blood test, usually taken at your health centre or hospital.
• Centro de salud — The centro de salud is your local public health centre, where your GP works.
• Consulta — The consulta is a doctor's appointment or clinic visit.
• Tratamiento al alta — The tratamiento al alta is the medication and care you must follow after leaving hospital.
• Seguimiento — The seguimiento is the follow-up section: check-ups (revisión) or referral to another specialist (derivación).

Key rules

• Right to copies: You can get your medical history and copies in public and private care, and the first copy is usually free.
• Language: Reports are issued in Spanish; translation is generally at your own expense.
• Check first: Check your allergies, medicines and follow-up sections for mistakes.
• Representative: Someone requesting your records for you needs your written authorisation and their ID.

What an informe de alta is

An informe de alta is the report the hospital gives you when you leave. It is written in Spanish, in medical shorthand. It tells your GP and any specialist what happened and what comes next. Keep it, and bring it to every later appointment.

"Se da de alta" means you are being discharged. You may also get an informe de urgencias (from the emergency department), an informe de consulta (from a specialist visit) or a parte de interconsulta (a note between departments).

How the report is laid out

Most reports follow the same order. The checklist below gives the quick version. Here is what each part means:

• Datos del paciente: your identity, your history number (NHC) and the dates you came in and left.
• Servicio: the hospital department that treated you.
• Motivo de ingreso: why you were admitted.
• Antecedentes personales/familiares: your past illnesses and your family's.
• Alergias: known allergies. Check this is right.
• Enfermedad actual: the story of the current problem.
• Exploración física: what the doctor found when examining you.
• Pruebas complementarias: the tests done, such as analítica, radiografía, TAC, RMN or ECG.
• Evolución: how you progressed during the stay.
• Juicio clínico or diagnóstico principal/secundarios: the main and secondary diagnoses.
• Procedimientos: any operations or procedures.
• Tratamiento al alta: the medicines to take after you leave.
• Recomendaciones/plan and seguimiento: advice and follow-up, either a revisión (a check-up) or a derivación (a referral to another specialist).
• Signature: the doctor who wrote it.

If you take only two sections away, make them the treatment and the follow-up. They tell you what to do next.

Getting your test results

Your GP or specialist orders tests electronically. Blood tests (analítica) are usually done at your centro de salud or the hospital's extraction unit, often fasting. Scans such as X-ray, ultrasound, MRI or CT are scheduled by the hospital's radiology department. They send the appointment by letter, SMS or phone.

Results are normally explained at a follow-up consulta with the doctor who ordered them. Most regions also let you see results and reports in their health app or portal. An abnormal result may prompt a phone call. Imaging reports can be given on a CD or found online. Online access and waiting times vary by region, so ask your centro de salud what your region offers.

Your right to understand and to get your records

You have a legal right to be given information in a way you can understand, so you can make decisions about your care. Ask the doctor to explain anything unclear, and ask again until it makes sense.

That right does not expressly include a translated report or a professional interpreter. Reports are issued in Spanish. In regions with a co-official language (Catalonia, the Basque Country, Galicia, Valencia, the Balearics) you can ask for the report in that language. Translation is generally at your own expense, though some regions run intercultural mediation or interpreting programmes. Private insurers may supply English reports.

You also have the right to see your full medical history (historia clínica) and get copies, in both public and private care. Ask the patient service (Atención al Paciente, Admisión or Archivo de historias clínicas) in writing, with your ID. The timeline below shows the steps. Replies usually take days to a few weeks and must come within one month. The first copy is usually free. Some public centres may charge for repeated or excessive copies.

Someone else can request it for you with your written authorisation and ID. The questions in the FAQ below cover this too.

Tips for reading it

• Copy unfamiliar terms into a translation tool, then confirm with your doctor.
• Check your name, dates, allergies and medicines for errors, and ask for a correction if you find one.
• Take the report to your GP soon after discharge so they can continue the treatment.

Timeline and deadlines

• Send a written request with your ID to the hospital or health centre's patient service: as soon as you want a copy of your records

• Receive your copy of your medical history: within one month of your request at most, often in days or a few weeks

Checklist

• Check the patient details at the top of the report: your name, history number (NHC) and the dates of admission and discharge.

• Find the motivo de ingreso, the reason you were admitted, and the diagnosis, called juicio clínico or diagnóstico principal.

• Read the tratamiento al alta to see which medication you must take after leaving, and check the alergias section is correct.

• Look at the seguimiento section for follow-up: a revisión, or a derivación to another specialist.

• Read pruebas complementarias for your tests, such as analítica (blood test), radiografía, TAC, RMN or ECG.

• Check your results in your regional health app or portal, or ask for them at the follow-up consulta with the doctor who ordered the tests.

• Ask for imaging reports on CD, or look for them online.

• Ask the patient service (Atención al Paciente or Archivo de historias clínicas) for a copy of your full historia clínica, with your ID and a written request.

• Give a representative a written authorization and their ID if they request your records for you.

Quick answers about medical paperwork in Spain

Can I get a copy of my medical history in Spain?

Yes, you have the right to get a copy of your medical history (historia clínica), in both public and private care. Ask at the patient service desk (Atención al Paciente, Admisión or the records archive) with your ID and a written request. The first copy is usually free, and the centre normally has up to one month to reply.

Can someone else request my medical records for me?

Yes, a representative can ask for your records if they bring your written authorization and their own ID. Many regions also let you see your records online through the regional health website or app, which avoids the trip.

Can I change my assigned family doctor in the public system?

Yes, you can ask to change your family doctor (médico de cabecera) in the public system, usually if the new doctor accepts new patients. Apply at the admissions desk of your health centre, on your regional health website or app, or by phone. Some regions limit changes to about once a year unless you have a good reason.

Can the pharmacist give me a different brand of my medicine?

Yes, the pharmacist can give you a cheaper medicine with the same active ingredient, dose and form, but not for every medicine. If your doctor prescribed the active ingredient, you get the cheapest option, usually a generic. Some medicines, such as levothyroxine, certain anticoagulants and antiepileptics, cannot be swapped.

What do I pay if I insist on a more expensive brand?

You pay the difference if you choose a brand that costs more than the reference price (precio de referencia). On public prescriptions you also pay the usual copayment, which depends on your income and age. Pensioners and some other groups pay less.