[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Forensic medicine](https://durgical.com/en/forensic-medicine/) › [A doctor's legal duties in Colombia](https://durgical.com/en/forensic-medicine/areas/duties/) › The medical record as evidence # 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. Updated Nov 5, 2026 ## Key points - In criminal proceedings the medical record is documentary evidence (Law 906, art. 424). - The judge weighs whether it was altered (art. 432): a crossed-out correction weakens it. - Judicial authorities have access in the cases the law provides (Resolution 1995 of 1999, art. 14). - Medico-legal death in the institution: the record goes to the director and is kept as evidence. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/forensic-medicine/the-medical-record-as-evidence/) ## Elsewhere in DurgiPedia - [Resolución 1995 de 1999: the medical record](https://durgical.com/en/medical-ethics/resolucion-1995-de-1999-the-medical-record/) ## Connections ## Related 3 - [Criminal liability in medical practice: negligent homicide and injury](https://durgical.com/en/forensic-medicine/criminal-liability-in-medical-practice-negligent-homicide-and-injury/) - [The expert report (dictamen pericial): what it must contain](https://durgical.com/en/forensic-medicine/the-expert-report-what-it-must-contain/) - [The duty to report a crime and its limits](https://durgical.com/en/forensic-medicine/the-duty-to-report-a-crime-and-its-limits/) [← All of forensic medicine](https://durgical.com/en/forensic-medicine/) 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](https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=14787) (Función Pública, Gestor Normativo, 2004); [Decreto 786 de 1990, autopsias clínicas y médico-legales](https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=168508) (Función Pública, Gestor Normativo, 1990); [Resolución 1995 de 1999, normas para el manejo de la historia clínica](https://www.minsalud.gov.co/Normatividad_Nuevo/RESOLUCI%C3%93N%201995%20DE%201999.pdf) (Ministerio de Salud, 1999); [Resolución 839 de 2017, conservación de la historia clínica](https://www.minsalud.gov.co/Normatividad_Nuevo/Resolucion%20No%20839%20de%202017.pdf) (Ministerio de Salud y Protección Social, 2017). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/forensic-medicine/the-medical-record-as-evidence/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/forensic-medicine/the-medical-record-as-evidence/