How long must a clinical record be kept in Colombia?

At least 15 years from the last visit, under article 3 of Resolution 839 of 2017: five in the active archive and ten in the central archive. The 20-year term of Resolution 1995 of 1999 no longer applies.

What must a psychology clinical record contain in Colombia?

Chronological, legible entries with no crossings-out or blank spaces, each with the date, name and signature of whoever wrote it (Resolution 1995 of 1999). In psychology it usually includes identification, reason for consultation, history, assessment, intervention plan, one progress note per session and the informed consents.

Is a psychologist required to keep a clinical record?

Yes, when practising in health (Law 1090 of 2006, article 10, and Doctrine No. 01 of the Colombian College of Psychologists). In other fields they keep a professional file of psychological intervention.

Can I keep the clinical record in Word?

The rules allow electronic media if they guarantee integrity and authorship. A Word document can be changed without a trace and records no per-entry signature, so complying with one depends entirely on your discipline and your backups.

Can a patient ask for a copy of their clinical record?

Yes. The record is confidential towards third parties, but the patient has the right to see it and to receive a copy.

GUIDE · REVIEWED 2026-09-25

Clinical records in psychology in Colombia: requirements, custody and digital format

What Colombian law asks of a psychologist's clinical record, rule by rule: when it is mandatory, what it must contain, how long to keep it and what changes when it is electronic. Quotations are from the Spanish originals.

Clinical record or professional file?

Law 1090 of 2006, article 10, requires psychologists to keep records of their interventions in clinical records and to hold them «en sitio cerrado y con la debida custodia» (in a closed place, under proper custody).

The Colombian College of Psychologists spells it out in its Doctrine No. 01: whoever practises in health is obliged to keep a clinical record; in other fields — education, organisations, forensics — they keep a professional file of psychological intervention. If you see clinical patients, yours is a clinical record.

What it must contain, under Resolution 1995 of 1999

The Ministry of Health's Resolution 1995 of 1999 defines the clinical record as «un documento privado, obligatorio y sometido a reserva» (a private, mandatory, confidential document) in which the patient's health and the professional's interventions are recorded chronologically. Its general rules:

It is written in chronological order, clearly and legibly.
No crossings-out, amendments, insertions or blank spaces, and no abbreviations.
Every entry carries the date and the full name and signature of whoever wrote it.
A correction does not erase what was written: a new note is added that explains it.
It may be kept electronically, as long as it cannot be altered and every entry's author is known.
In clinical practice, a psychology record usually gathers identification, reason for consultation, history, assessment and diagnostic impression, intervention plan, one progress note per session, informed consents and discharge.

How long to keep it: 15 years

Resolution 839 of 2017, article 3, sets the term: the clinical record is kept for «un periodo mínimo de quince (15) años, contados a partir de la fecha de la última atención» — at least fifteen years from the last visit. The first five years in the active archive and the next ten in the central archive.

The term doubles when the patient is a victim of human-rights violations or serious breaches of international humanitarian law.

If you read elsewhere that it is 20 years: that was the term in Resolution 1995 of 1999, and Resolution 839 of 2017 replaced it.

Confidentiality, professional secrecy and sensitive data

The clinical record is confidential: only the patient, the health team treating them, judicial and health authorities in the cases the law provides, and whoever the patient authorises may see it.

Health data is sensitive data under Law 1581 of 2012. Processing it requires the patient's express authorisation and matching security measures: control over who has access, backups and a log of every time the record is opened.

Electronic clinical records and interoperability (IHCE)

Keeping the record in software has been valid since Resolution 1995 of 1999, provided integrity, authorship and preservation are guaranteed.

Law 2015 of 2020 created the interoperability of the electronic clinical record (IHCE), so that a patient's relevant clinical data can be consulted across providers «respetando el Hábeas Data y la reserva». Resolution 866 of 2021 defined that data set and Resolution 1888 of 2025 adopted the Resumen Digital de Atención (RDA).

The obligation for independent professionals is being applied in phases. Confirm your case with your department's health secretariat or through your REPS registration.

Paper, Word or a clinical records platform

The rules do not require a format; they require properties. This is how the three most common ways of keeping a record compare:

REQUIREMENT	PAPER	WORD OR EXCEL	CLINICAL RECORDS PLATFORM
Chronological record without amendments	Depends on your discipline	The file can be edited without a trace	If the system locks what is signed and corrects with notes
Signature on every entry	Handwritten signature	No per-entry signature	Electronic signature per progress note
15-year custody	Physical archive, at risk of loss	Depends on your backups	The provider's duty, by contract
Knowing who opened the record	No	No	If the system logs it
Giving the patient a copy	Photocopy	Export and send	Full export