The medical records is the most important document of your professional practice. It is not only a record of what happens in session — is a legal, clinical and ethical instrument that supports your work, protects the patient and can be decisive in a judicial process or an audit of the professional college.

Despite this, many psychologists in Argentina are not clear what should contain, how long to keep it or what format to use. In this article we explain everything you need to know.

What is the medical records?

The 26.529 (Patient Rights) Act defines the medical records as:

"The mandatory chronological, foliated and complete document in which all actions performed to the patient by health professionals and auxiliaries are recorded."

In psychology, this translates into the systematic registration of everything relevant for patient care: from the initial reason of consultation to the notes of each session, through diagnoses, interventions, referrals and discharge.

Note

The medical records is a right of the patient, not a property of the professional. The patient can request a copy at any time and you are obliged to deliver it.

Legal framework in Argentina

Law 26.529 — Rights of the Patient

It is the main law governing medical records (Chapter IV, Art. 12-21). It establishes:

Art. 12 — Definition: Document mandatory, chronological, foliate and complete in which all actions performed to the patient are recorded
Art. 14 — Ownership: The patient is the holder of the medical records. At his simple request he must be provided with an authenticated copy within 48 hours of request.
Art. 18 — Inviolability and deposit: The medical records is inviolable. The professionals are depositaries and must implement the means to avoid unauthorized access. Minimum retention time: 10 years since the last recorded performance
Art. 13 — HC Computerized: Can be made in magnetic support guaranteeing: integrity, authenticity, unalterability, durability and recoverability
Art. 15 — Seats: Defines the minimum mandatory content
Art. 16 — Integrity: The informed consents, medical indications, protocols, prescriptions and studies carried out are part of the HC.

Law 26.657 — Mental Health

Strengthens the protection of patient rights in the field of mental health:

Art. 5: The existence of a mental health diagnosis does not allow the presumption of risk of harm or disability, which can only be inferred from an interdisciplinary assessment of each particular situation
Art. 7.i: Right to not be identified or discriminated against by a current or past mental condition
Art. 7.g: Right of the patient, his or her lawyer, a relative or relative to access to his or her history, records and medical records
Art. 7.l: Right to treatment with the protection of privacy and full respect for his private life
Art. 15: In hospitalization, the evolution and each intervention of the team should be registered daily in the medical records

Law 25.326 — Protection of Personal Data

Health data are sensitive data (Art. 2). Art. 8 specifically empowers health professionals to collect and process data relating to the health of their patients, respecting the principles of professional secrecy. This implies:

Duty of information to the patient (Art. 6): purpose, existence of the archive, rights
Technical and organisational security measures to ensure integrity and confidentiality (Art. 9)
Right of the patient to access (Art. 14 — 10 straight days), rectification and deletion (Art. 16 — 5 working days)
Deletion does not take place where there is a legal obligation to keep the data (Art. 16.5)

Provincial regulations

Some provinces have additional regulations, for example:

Buenos Aires: 15.464 Law on Electronic medical records
CABA: 153 Law (Basic Health Law) with provisions on registries
Córdoba, Santa Fe, Mendoza: own regulations that complement national law

Important

Check with your provincial professional college to learn about the specific regulations of your jurisdiction. Some provinces have additional requirements about formatting and content.

What should the medical records contain?

Data required under the 26.529 Act (Art. 15)

The law provides that at least:

(a) The start date of its manufacture
(b) Patient identification data and its family nucleus
(c) Professional identification data involved and its speciality
(d) Clear and precise records of acts performed by professionals
(e) Genetic, physiological and pathological background of the patient, if any
g) Any medical act performed or indicated: prescriptions, treatments, studies, presumptive and certain diagnosis, prognosis, procedure, evolution, income and high

In addition, Art. 16 states that informed consents, medical indications, surgical protocols, prescriptions and studies performed, rejected or abandoned are part of the medical records:.

Digital or paper?

medical records on paper

Advantages:

No technology required
Some professionals prefer it by habit

Disadvantages:

You may lose, damage, or deteriorate
Hard to organize and search for information
It occupies physical space.
Cannot be accessed from another location
Difficult to meet the "foliate" requirement if not rigorous

Digital medical records

Advantages:

Access from anywhere
Quick search for information
Automatic backups
Easily meet the chronological and foliated requirement
Facilitates delivery of copies to the patient
Better security with encryption

Disadvantages:

Requires reliable software
You need to ensure data security

Note

Article 13 of the 26.529 Law explicitly accepts the computerized medical records. It must determine all means that ensure the preservation of its integrity, authenticity, unalterability, durability and recoverability data. To this end, the use of restricted accesses with identification keys, non-rescribeable means of storage and field modification control must be adopted.

Requirements for digital medical records (Art. 13)

If you choose the digital format, the system must guarantee the five requirements of Art. 13:

Integrity: that data cannot be altered without recording
Autentity: that can be verified who made each record
Unchangeability: that the records already registered cannot be modified
Perdurability: that data is stored over time without deterioration
Recoverability: that data can be accessed in time and form

To achieve this, Art. 13 requires: restricted accesses with identification keys, non-rescribeable storage means and field modification control.

How long do you have to keep your medical records?

The legal minimum: 10 years

Article 18 of the 26.529 Law provides that the obligation of custody and custody must apply for a minimum period of 10 years of prescription for the release of contractual liability, calculated from the last recorded act in the medical records. If you served a patient until 2026, you must keep his or her medical records at least until 2036. After that period, the depositary shall have it as determined by the regulations.

Professional recommendation: keep indefinitely

Many professional colleges and ethics experts recommend keeping medical records indefinitely, especially in digital format where storage is not a problem. Reasons:

Legal claims: limitation periods may be extended in certain cases
Continuity of care: The patient may return years later
Research: material may be useful for research (anonymized)
Professional protection: against an ethical complaint, the medical records is your main defense

What about minors?

The 26.529 Act does not make an explicit distinction for minors as to the period of retention. Article 18 states that 10 years are counted from the last recorded act. However, since the limitation periods for civil liability for damages to minors may be extended (the Civil and Commercial Code establishes that the statute of limitations does not apply to minors), it is prudent to retain the medical records at least until the minor reaches the age of majority plus the applicable statute of limitations.

Important

The premature destruction of a medical records can have serious legal consequences. Faced with doubt, it retains.

Who can access the medical records?

The patient (Art. 14 and 19.a)

Always. The patient is the holder of the medical records (Art. 14). At his simple request must be provided authenticated copy within 48 hours of request, except in case of emergency. If you refuse access, the patient can exercise the action of habeas data (Art. 20).

Legal representative (Art. 19.a)

In the case of minors or persons with restricted capacity, their legal representatives may apply for a medical record.

Spouse, cohabitant and forced heirs (Art. 19.b)

The spouse or person living with the patient, and the forced heirs, may access with the consent of the patient, unless the patient is unable to give it (e.g. by death or disability).

Other health professionals (Art. 19.c)

Physicians and other professionals in the art of healing may access with the express consent of the patient or their legal representative. Ideally, with a signed confidentiality agreement.

Judicial authorities

Article 2.d of the law states that the confidentiality of clinical documentation must be respected unless "expresses a provision to the contrary emanated from the competent judicial authority." Upon a judicial request, you have the right to deliver only what is relevant to the case.

Name: Lic. [Name and Surname]
professional license: M. P. [Number]
Speciality: [Focus/speciality]
Professional address: [Address]
Telephone/Email: [Contact]

PATIENT DATA

Full name: [Name and Surname]
DNI: [Number]
Date of birth: ________________
Age: [Age]
Civil State: [State]
Occupation: [Occupation]
Domicile: [Address]
Telephone: [Number]
Email: [Mail]
Health insurance/private health plan: [Name and Affiliate number]
Emergency contact: [Name, link, telephone]

GROUND FOR CONSULTATION

In the words of the patient:

[Record textually what the patient refers to as a reason for consultation]

Professional reformulation:

[Your clinical reading of the reason for consultation]

Delivered by: [Name of the professional / institution / spontaneous consultation]

BACKGROUND

Previous psychological treatments:

Period	Professional	Approach	Reason	Outcome

psychiatry treatments:

Period	Professional	Medication	Current dose

relevant medical records:

[Medical conditions, surgeries, hospitalizations]

relevant family records:

[Family history of psychological/psychiatric disorders]

INITIAL ASSESSMENT

Mind state:

Area	Observation
Overview
Orientation (time, space, person)
Attention and concentration
Memory
Language
Thought (form and content)
Affect
Sensoperception
Trial and Self-Criticism
Basic functions (dream, appetite)

Applied instruments:

Date	Instrument	Outcome

Diagnostic hypothesis:

[Presumptive diagnosis with criteria or theoretical framework used]

TREATMENT PLAN

Theoretical approach [Theoretical framework]
General objectives: [List]
Specific objectives: [List]
Frequency: [Week/fifth]
Modality: [Present/online/mixed]
Estimated duration: [If possible to estimate]
Release criteria: [What needs to be achieved]

EVOLUTION NOTES

Session N°: [Number] — Date: ________________

Assistance: [ ] Present [ ] Absent with notice [ ] Absent without notice

Worked topics:

[Clinical content of the session]

Interventions made:

[Applied techniques, markings, interventions]

Clinical observations:

[Emotional status, observed changes, relevant material]

Plan / Next session:

[Tasks, topics to be taken up, agreements]

[Repeat the Evolution Notes section for each session]

CLOSURE

Date of closure: ________________
Motivation: [ ] High therapeutic [ ] Derivation [ ] Patient decision [ ] Abandonment [ ] Other: _____
State at closure: [Final assessment]
Indications: [Post-high recommendations]

Professor's signature: _____________________

Seal: _____________________

How to manage your medical records with Brauni

Brauni is designed specifically to make the management of the medical records simple, safe and legally sound. The complete detail is in digital medical records; these are the key points:

Dynamic Templates: Customize the structure of your medical records according to your theoretical approach and needs
Automatic chronological record: Each note is automatically dated and numbered
Linked consent: Informed consent is attached to the patient's file
End-to-end encryption: Your clinical records are protected with the highest safety standards
Controlled access: Only you access the information of your patients
Auto-Backups: You will never lose a medical records
Export: Generates a complete copy in PDF when requested by the patient

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Summary

Concept	Description
What is it?	Mandatory, chronological, foliated and complete document (Art. 12, Law 26.529)
Is it mandatory?	Yes, by law 26.529
Titleality	The patient is the holder (Art. 14). The professional is the depositary (Art. 18)
How much do you keep?	Minimum 10 years since last performance (Art. 18). Recommended: indefinitely
Digital or paper?	Both are valid. Art. 13 accepts magnetic support guaranteeing integrity, authenticity, unalterability, durability and recoverability
Copying delivery	Within 48 hours of application (Art. 14). If refused, the patient may exercise habeas data (Art. 20)
Who can access?	Patient (Art. 19.a), legal representative (19.a), authorized spouse/heirs (19.b), licensed professionals (19.c), judicial authority (Art. 2.d)

Element	Description
Patient data	Full name, DNI, date of birth, address, telephone, email, health insurance
Professional data	Name, registration, specialty, contact details
Opening date	When the attention was started
Source of referral	Whoever derived it (if applicable)
Reason for consultation	In the words of the patient and professional reformulation
Informed consent	Signed and dated

Element	Description
Personal background	Previous treatments, current medication, hospitalizations
Family records	Relevant psychiatric/psychological family history
Life Story	Significant biographical data for the understanding of the case
Initial mental state	Clinical observations from the first interview
Applied assessments	Tests, scales or psychodiagnosis instruments (with results)
Diagnostic hypothesis	Presumptive diagnosis with criteria used

Element	Description
Therapeutic approach	Main theoretical and technical framework
Objectives	General and specific, ideally measurable
Frequency	Weekly/fifty/monthly meetings
Modality	Face-to-face, online or mixed
Estimated duration	If possible estimate
Registration criteria	What needs to be achieved in order to complete

Element	Description
Date and session number	Timely registration
Assistance	Present, absent with notice, absent without notice
Content of the session	Topics worked, relevant clinical material
Interventions	Techniques applied, markings, interpretations
Emotional state	Observations on the patient's condition
Plan for next session	Tasks, outstanding issues

Element	Description
Date of closure	When the attention ended
Reason for closure	Therapeutic high, abandonment, referral, patient decision
State at close	Final patient evaluation
Post-high indicators	Recommendations, suggested follow-up

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