Medical Records and Documentation in Colombia: Getting Copies to Take Home and Share

The paperwork from your operation in Colombia is part of your treatment. The doctor who checks your wound at home, a surgeon who might one day revise the result, an anesthetist planning a later operation and an insurer reviewing a claim will all want to see what was done, with what, and how you recovered. Most of that information sits in a Colombian document called the historia clínica. This guide explains what it contains, what rights you have to it, what to ask for before you leave, and how to make it usable once you are home.

If you are still planning and want to know which of your existing records to send to a Colombian surgeon before the operation, see What medical records should you send before surgery abroad? This article is about the records Colombia produces about you.

What the historia clínica is

Colombia's rules on clinical records come mainly from Resolución 1995 de 1999 of the Ministry of Health. It defines the historia clínica as a private, mandatory document subject to confidentiality. It records, in date order, your health condition, the medical acts performed and the other procedures carried out by the care team. Third parties may see it only with your authorisation or where the law allows (MinSalud, Resolución 1995 de 1999, art. 1).

The resolution divides the record into three parts (arts. 8 to 11):

• Identification: your name, ID document, date of birth, sex, address and insurance details. For a visitor this usually means your passport number.
• Specific records: the notes for each type of care you receive, such as consultations, the operation, anesthesia, nursing and the hospital stay.
• Annexes: supporting documents, including your signed informed consent for surgery and any voluntary discharge statement.

Your right to see and copy it

Two legal sources work together here. The 1999 resolution says the patient may access the record, and that the provider "may" give a copy to the patient or their legal representative on request (arts. 13 and 14). That wording is permissive. Colombia's later statutory health law is stronger: it gives patients the right to consult their complete record free of charge and to obtain a copy (Ley Estatutaria 1751 de 2015, art. 10).

In practice, most reputable providers will hand over copies to a patient who asks clearly and shows ID. Whether a provider charges an administrative fee for printing or digital copies is something to ask in advance. This guide does not cover the rules on fees.

The Spanish names to ask for

Asking for "my records" can get you a one-page summary. Asking for documents by name gets you the file. These are the terms you are most likely to need:

If you received an implant, ask for the implant identification details: the manufacturer, model, size and lot or serial number, usually printed on stickers or a card. These are hard to recover later and matter if a product question ever arises.

When and how to ask

The easiest time to get records is while you are still in the country and still in contact with the team. A sensible sequence:

1. Before surgery: say in writing, by email or message, that you will need full copies before you fly home, and ask how the clinic prefers to handle requests.
2. At discharge: collect the discharge summary, prescriptions and anything already available.
3. At your final in-person check: ask for the complete record, including the operative and anesthesia notes. Pathology results can take longer, so agree how they will be sent.
4. Before you leave the building: check that every page is there, that your name and passport number are on it, and that the dates are right.

Bring your passport when you ask. Because the record is confidential, a provider may refuse to release it to a companion without your written authorisation. If someone else will collect documents for you, ask the clinic what form of authorisation it accepts.

Paper or digital?

Colombian providers may keep records on paper or electronically. The 1999 resolution allows computer systems, provided they prevent changes once data is saved and identify who made each entry and when (MinSalud, Resolución 1995 de 1999, art. 18). For you, the best outcome is both: a searchable PDF you can email and a printed set you carry in your hand luggage.

• Ask for imaging in a standard medical format on a disc or download link, plus the written report. Many clinics at home cannot open unusual viewers.
• Save everything in two places, such as a cloud folder and a USB stick.
• Name files clearly, for example "2026-10-14 operative report Spanish.pdf."

Translation

The CDC advises medical tourists to ask for their overseas records in English and to share them with future clinicians (CDC Yellow Book, 2026). Some Colombian clinics that treat many international patients can provide an English summary. Others cannot. Options, in rough order of usefulness:

• An English discharge letter written by the surgeon, in addition to the Spanish record (not instead of it).
• A professional medical translation of the key documents: the operative report, anesthesia record and discharge summary.
• Keep the Spanish originals in all cases. If there is ever a dispute, the original is what counts.

The same applies to documents you sign before surgery. Our guide to translated consent explains how to make sure you understand them.

How long Colombia keeps the record

The 1999 resolution requires providers to keep the record for at least 20 years after the last care episode: at least five years in the active archive and at least 15 in a central archive. The provider that created the record holds custody. If a provider is liquidated, the liquidator must assign a custodian and inform the health authority (MinSalud, Resolución 1995 de 1999, arts. 13 and 15). Rules are not the same as easy access, though. Requesting records years later from another continent is slow, and small clinics change hands. Your own copy is the one you can rely on.

If something is missing after you get home

Gaps often only show up when a doctor at home asks for a document you don't have. If that happens:

• Write to the clinic, in Spanish if you can, listing exactly which documents you need and the dates of care.
• Attach a copy of your passport and say how you want to receive the documents, for example as a PDF by email.
• Keep a copy of every request and the date you sent it.
• If the clinic does not reply, ask for the name of its patient services office. Colombian law entitles patients to be told the formal complaint channel and to receive a written answer (Ley 1751 de 2015, art. 10).

Sharing the record at home

Give a copy to your family doctor before your first follow-up appointment, not on the day. Our guide to coordinating follow-up with your home physician covers how to set that up. Keep a one-page cover sheet on top of the file listing:

• The operation, the date and the facility
• The surgeon's and anesthesiologist's names and contact details
• Any implants, with identification details
• Medicines you went home on
• Any complications during the stay

That page lets a busy clinician understand your trip in a minute, and points them to the detail when they need it. This article is general information, not legal or medical advice.

Frequently asked questions