patientenrechte-akteneinsicht

/medizinrecht:patientenrechte-akteneinsicht

Purpose

The skill examines the right to inspect the treatment documentation under § 630g BGB and the parallel right of access under Art. 15 GDPR. Both rights exist alongside each other (concurrence of claims). The skill examines grounds for refusal (therapeutic reservation, rights of third parties), form (original, copy, electronic), cost consequences and the heir's right under § 630g (3) BGB. Interfaces with § 203 StGB (duty of confidentiality; protection of the deceased) and with advance directives §§ 1827 et seq. BGB are also examined.

Inputs

Treatment relationship (treating party, period, content of the record, if applicable third-party medical findings, images)
Applicant (patient personally / legal representative / heir / other relative)
In the case of an heir's claim: date of death, status as heir, asserted pecuniary or non-pecuniary interests
specific grounds for refusal on the treating party's side
Form desired (inspection on site, copies, electronic transmission)

Sub-agent architecture

Researcher provides § 630g BGB, Art. 15 GDPR, § 22 BDSG, § 203 StGB, BGH case law on the restrictive application of the therapeutic reservation, the line on heirs, commentary references (Spickhoff, Laufs/Katzenmeier/Lipp, Wagner in MüKoBGB). Drafter prepares the letter asserting the claim or a statement against refusal in the style of a legal opinion. Reviewer examines the restrictive application of the exceptions and the relationship between BGB/GDPR (in particular costs, form, time limit).

Procedure

1. Legal basis § 630g BGB

§ 630g (1) sentence 1 BGB: "Upon request, the patient shall be granted without undue delay inspection of the complete patient record concerning him or her, insofar as inspection is not opposed by significant therapeutic reasons or other significant rights of third parties."

Statutory requirements:

Patient (contracting party to the treatment contract § 630a BGB)
Request (request not subject to any form; as a rule in writing for evidentiary reasons)
without undue delay – without culpable hesitation, § 121 I BGB standard; in practice as a rule within a few weeks
complete – incl. raw findings, images, correspondence with co-treaters/previous treaters, surgical reports, nursing documentation
concerning him or her – no patient record of third parties

2. Grounds for refusal (to be construed narrowly)

§ 630g (1) sentence 1 second half of the sentence BGB names two grounds for refusal:

Significant therapeutic reasons – BGH line: restrictive; a merely theoretical endangerment of the success of treatment is not sufficient; a concrete, documented danger to the patient's psychological stability (in particular psychiatry) is required.
Significant rights of third parties – e.g. information provided by third parties (family history) with their interest in confidentiality; if applicable redaction; complete refusal rarely permissible.

The refusal is under § 630g (1) sentence 2 BGB to substantiate. Blanket refusal (“therapeutic reasons”) does not hold up.

3. Form and costs

Original file remains with the treating party; entitlement to copies under paragraph 2.
Electronically maintained file: an electronic copy (PDF, image resolution, MRI DICOM) suffices; in the case of a purely electronic file, it must also be provided in electronic form.
Costs: § 630g(2) sentence 2 BGB refers to § 811 BGB – the patient must reimburse the costs. Rule of thumb: €0.50 per copy, shipping costs in addition; if the patient requests electronic transmission, the costs actually incurred (low) apply.

4. In parallel: Article 15 GDPR

The patient additionally has a right to information and to a free copy of the data under Article 15(3) GDPR (first copy free of charge; further copies for a reasonable fee). Both claims exist in genuine concurrence of claims (prevailing view) – the patient may choose. Practical tip: base the initial request on Article 15 GDPR, because it is free of charge and subject to the strict GDPR deadline (usually one month, Article 12(3) GDPR); the file contents largely coincide.

CJEU on data copies in connection with patient files: judgment of 26.10.2023 – C-307/22 (FT/DW) (https://curia.europa.eu/juris/document/document.jsf?docid=279125&doclang=DE) – right to a free first copy of the patient file confirmed; national cost rule (§ 630g II 2 BGB) takes a back seat to the extent that the patient requests information under Article 15 GDPR.

5. Heirs’ claim § 630g(3) BGB

After the patient’s death, the right of inspection is held by:

the heirs for the pursuit of financial interests (e.g. review of treatment errors for a damages claim);
the closest relatives for the assertion of non-material interests (e.g. clarification of the cause of death).

Both claims lapse to the extent that there is a conflicting express or presumed will on the part of the patient. The burden of proof for the conflicting will lies with the treating party; mere assumptions do not suffice. BGH line on the restrictive application of the presumed will [unverifiziert – prüfen in juris].

6. Interface § 203 StGB

The physician’s duty of confidentiality (§ 203 StGB, § 9 MBO-Ä in the respective LBO) applies beyond death. Information may be provided to heirs/relatives only to the extent that § 630g(3) BGB permits it; in this respect there is a statutory authorizing provision that excludes the elements of § 203 StGB. In case of doubt: obtain a declaration releasing the patient from confidentiality during their lifetime or have the status as heir proven by document (certificate of inheritance).

7. Relationship to advance directive

If the patient had an advance directive under §§ 1827 et seq. BGB (n.F. since the 2023 care law reform; formerly §§ 1901a et seq. BGB) is established, it may also contain a release from confidentiality. The drafter should request the document.

Sources and Citation Style

Binding: ../../../references/zitierweise.md.

Statute

§ 630g BGB (access to records)
§ 630f BGB (documentation duty – basis of the object of inspection)
§ 811 BGB (cost rule via § 630g II 2 BGB)
§§ 1827 et seq. BGB (advance directive)
Art. 15 GDPR, Art. 9 GDPR (health data)
§ 22 BDSG (processing of special categories of personal data)
§ 203 StGB (duty of confidentiality)
possibly § 10(3) MBO-Ä (professional-law duty of inspection and retention; 10 years, possibly longer)

Commentaries

Wagner, in: MüKoBGB, 9th ed. 2024, § 630g marginal no. 1 et seq.
Katzenmeier, in: BeckOK BGB, as of 2024, § 630g marginal no. 1 et seq.
Spickhoff, in: Spickhoff, Medizinrecht, 4th ed. 2022, § 630g BGB marginal no. 1 et seq.
Laufs/Katzenmeier/Lipp, Handbuch des Arztrechts, 8th ed. 2021, Ch. VI (documentation and right of inspection)
Bäcker, in: Kühling/Buchner, GDPR/BDSG, 3rd ed. 2020, Art. 15 GDPR marginal no. 1 et seq.

Case law

BGH, judgment of 26.02.2013 – VI ZR 359/11 (right of inspection; restrictive application of the therapeutic reservation) (https://dejure.org/dienste/vernetzung/rechtsprechung?Gericht=BGH&Datum=26.02.2013&Aktenzeichen=VI+ZR+359/11)
BGH line on heirs' inspection and the presumed will of the deceased [unverifiziert – prüfen in juris]
ECJ, judgment of 26.10.2023 – C-307/22, FT/DW (free first copy of the patient file under Art. 15(3) GDPR) (https://curia.europa.eu/juris/document/document.jsf?docid=279125&doclang=DE)
OLG case law on image recordings / X-ray images / DICOM data [unverifiziert – prüfen in juris]

Output format

GUTACHTEN / ANSPRUCHSSCHREIBEN — Akteneinsicht
Mandat:  <anonymisiert>
Behandler: <Klinik/Praxis>
Zeitraum: <…>

I.   Sachverhalt (knapp)
II.  Frage(n)
III. Kurzantwort
     – Anspruch dem Grunde nach: [ja / nein / teilweise]
     – Empfohlene Anspruchsgrundlage: [§ 630g BGB / Art. 15 DSGVO / beide]

IV.  Rechtliche Bewertung
     1. § 630g BGB
        a) Anspruchsinhaber (Patient / Erbe / Angehöriger)
        b) Vollständige Akte
        c) Verweigerungsgründe
           – therapeutischer Vorbehalt
           – Rechte Dritter
        d) Form (Einsicht / Kopie / elektronisch)
        e) Kosten
     2. Art. 15 DSGVO (parallel)
        – Frist Art. 12 III DSGVO
        – Kostenfreie erste Kopie Art. 15 III DSGVO
     3. Schnittstelle § 203 StGB / § 22 BDSG / Art. 9 DSGVO
     4. Bei Erbenanspruch: § 630g III BGB, mutmaßlicher Wille

V.   Empfehlung
     – Antragstellung
     – Frist
     – Eskalation (Aufsichtsbehörde, Klage AG/LG)

VI.  Risiken / offene Punkte
     🟢 / 🟡 / 🔴

VII. Quellenverzeichnis

Risks / typical errors

Blanket refusal on "therapeutic grounds" without concrete justification – does not stand up (§ 630g I 2 BGB).
Misjudging the concurrence of claims § 630g BGB ↔ Art. 15 GDPR – Art. 15 GDPR is usually more favorable (free of charge, one-month deadline).
Rejection of inspection by heirs with a blanket reference to § 203 StGB – § 630g III BGB is a statutory authorization and excludes the offense.
Forgetting image recordings / DICOM data – "complete" also includes raw data.
Reference to the 10-year retention period § 10 MBO-Ä as an argument for destruction – minimum period, not maximum period; in view of § 199 II BGB (30-year maximum period), longer retention is in fact required.
Overlooking the advance directive §§ 1827 et seq. BGB n.F. (release from confidentiality).