The medical record as evidence
- Topic
In criminal proceedings the medical record is documentary evidence: it shows what was found, what was done and when, and must be kept unaltered.
What it is
The medical record is a private and confidential document, but judicial authorities may access it in the cases the law provides. In criminal proceedings (Law 906 of 2004) it is documentary evidence: the code counts as documents written texts, data messages, X-rays, ultrasound scans, CT scans, electrocardiograms and electroencephalograms (art. 424). The judge weighs whether the document has been altered and whether it shows the facts clearly (art. 432). When a death in an institution requires a medico-legal autopsy, the record is handed to the director and kept as evidence. The general rules on completing and keeping records are in Medical ethics.
Key facts
- Resolution 1995 of 1999, art. 14: the patient, the care team, judicial and health authorities in the cases provided by law, and other people the law names may access the record, always under confidentiality.
- Law 906, art. 424: documents include written texts, data messages, photographs, X-rays, ultrasound scans, CT scans and electrocardiograms, among others.
- Law 906, art. 432: the judge checks that the document has not been altered in form or content and that it shows the fact clearly.
- Decree 786 of 1990, art. 8, paragraph 1: if a death in a health facility requires a medico-legal autopsy, the doctor immediately hands the medical record to the director, who keeps it as evidence.
- Resolution 839 of 2017, art. 3: the record is kept for at least 15 years after the last visit; the period doubles for victims of human rights or international humanitarian law violations.
- Law 906, art. 385: the doctor-patient relationship is an exception to the duty to testify; judicial access to the record follows the rules of the law.
Next step: what to do and document
- Write each note at the time, with date, time, name and signature; describe injuries with site, shape and size.
- Record the patient's account in quotation marks, separate from the findings, and note who was with them.
- Never alter a note: additions go in a new note with date, time and reason.
- Give a copy of the record to a judicial authority only with a written order or in the cases provided by law, and keep proof of delivery.
- For medico-legal deaths in the institution, hand the original record to the director for safekeeping.
Legal framework in Colombia
- Law 906 of 2004, arts. 382, 385, 424 and 432; Decree 786 of 1990, art. 8, compiled in Decree 780 of 2016 (art. 2.8.9.8).
- Ministry of Health Resolution 1995 of 1999, art. 14, and Resolution 839 of 2017, art. 3; before quoting retention periods, confirm at minsalud.gov.co that they are still in force.
- Official text checked on 2026-11-05 at funcionpublica.gov.co (Law 906 of 2004 and Decree 786 of 1990) and minsalud.gov.co (Resolutions 1995 of 1999 and 839 of 2017).
Test yourself
Think of the answer, then tap the question to see it.
What kind of evidence is the medical record in Colombian criminal proceedings?
Documentary evidence: Law 906 (art. 424) includes texts, data messages and diagnostic images such as X-rays and CT scans.
What happens to the medical record if a patient dies in the institution and the case needs a medico-legal autopsy?
The doctor hands it at once to the director or their substitute, who keeps it as evidence (Decree 786 of 1990, art. 8, paragraph 1).
Can judicial authorities access the medical record?
Yes, in the cases provided by law and maintaining confidentiality (Resolution 1995 of 1999, art. 14).
How is a mistake in an already signed note corrected?
With a new dated note explaining the correction, never by crossing out or rewriting, because the judge weighs whether the document was altered.
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Connections
Educational content on forensic and legal medicine; not legal advice and no substitute for the technical guides of Colombia's National Institute of Legal Medicine and Forensic Sciences. Laws change: each page links the official text and says when it was last checked. For a real case, follow the guide in force and ask the competent authority.
Sources: Ley 906 de 2004, Código de Procedimiento Penal (Función Pública, Gestor Normativo, 2004); Decreto 786 de 1990, autopsias clínicas y médico-legales (Función Pública, Gestor Normativo, 1990); Resolución 1995 de 1999, normas para el manejo de la historia clínica (Ministerio de Salud, 1999); Resolución 839 de 2017, conservación de la historia clínica (Ministerio de Salud y Protección Social, 2017).
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