Clinical history in psychology is the legal and professional document recording the therapeutic process. Not optional: it's a legal obligation with specific requirements for health data.
Mandatory content
- Identification data.
- Anamnesis.
- Assessment: tests, observations.
- Treatment plan.
- Evolution notes.
- Documents: consents, referrals.
- Closing.
Indicative digital template
- Header: identification + alerts.
- Sessions table with date, reason, intervention.
- Professional's private notes.
- Associated documents (PDFs).
- Active packs, invoices and payments.
- Change log.
GDPR and special category
- Robust legal basis: explicit consent.
- Encryption at rest and in transit.
- EU servers.
- Role-based access control.
- Traceability.
Retention deadlines
- Legal minimum: 5 years.
- Some Spanish regions: 15 years.
- Minors: 5-10 years post age of majority.
- Judicial proceedings: may extend.
Patient's right of access
- Right to copy.
- Private notes may be excluded.
- Third-party data anonymised.
- Deadline: 30 days.
Suitable clinical software
- Unified file structure.
- AES-256 encryption.
- EU servers.
- DPA available.
- Access auditing.
- PDF export.
Typical mistakes
- Notes in paper notebook without copy.
- Sharing documents via unencrypted email.
- Personal Google Drive without contract.
- Mixing clinical and personal notes.
- Keeping beyond legal deadlines.
Preguntas frecuentes
Common questions about clinical history.
How long to keep clinical history?
Legal minimum 5 years. Some regions 15.
Can I keep records only on paper?
Legally yes, but bad practice.
Can the patient request their history?
Yes, they have the right. 30 days to deliver.
Do I need permission to share with another professional?
Yes, except in emergencies or judicial requirements.
Which software for digital clinical history?
Software with encryption, EU servers and a DPA.