Medical Records Regulation for Clinics
The medical records regulation for a physiotherapy practice: which sections apply to you, what changed in 2025-2026 and what to check.
The regulation on medical records runs to several dozen sections, and most of them do not concern a physiotherapy practice. Hospitals, emergency services, midwives, school health care, dentists: everything sits in one act. You need a dozen or so provisions. This article shows which ones, and what changed in the consolidated text published in autumn 2026 compared with January.
We work on the consolidated text announced by the Minister of Health on 4 September 2026 (Journal of Laws 2026 item 1391). This is not another guide to what to write in the patient record. For a step-by-step description of the documents, see our article on medical records in physiotherapy. Here you get a map of the regulation itself: where to look for answers and what to watch after amendments.
In brief
- Full name: Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (rozporządzenie w sprawie rodzajów, zakresu i wzorów dokumentacji medycznej). It was issued under Article 30(1) of the Act on Patient Rights.
- For a physiotherapist in a professional practice the key provisions are: the general rules (§§ 1-11), chapter 5 (§ 62), the content of the record in § 49(4), and retention and disclosure (§§ 69-71).
- The rule is that records are kept in electronic form (§ 1(1)). Paper is the exception (§ 1(2)).
- From 1 January 2026 the changes include § 7(1), § 9(2) (referrals) and § 10(1) (identification of the entity). The June 2026 amendments concern hospitals and the adoption of a child.
- The regulation does not set the retention period or fees for copies. Those stay in the Act on Patient Rights.
What the medical records regulation covers
The Act on Patient Rights says that a patient has the right to access records, and that the provider must keep, store and disclose them. The regulation answers a different question: what the records look like, meaning their types, their content and how they are processed.
First, the classification in § 2. Records are either individual (about a specific patient) or collective (about a group of patients). Individual records are either internal, kept for the provider's own needs, or external, issued for the patient's needs. For a practice it looks like this:
| Type | What it means for a physiotherapist | Where in the regulation |
|---|---|---|
| Individual internal | The individual physiotherapy care record (karta indywidualnej opieki fizjoterapeutycznej) | § 2(3)(7), § 62(1)(1) |
| Individual external | A physiotherapy certificate, ruling or opinion, and other documents issued at the request of the patient or authorized bodies | § 62(1)(2) |
| Referral | A document you receive from a doctor (or issue yourself, if your powers allow it) | § 2(4)(2), § 9 |
| Collective | A list of physiotherapy services in a medical rehabilitation facility | § 49(1) and (3) |
Note the last row. The collective list applies to a medical rehabilitation facility, that is, a medical entity. A professional practice has its own chapter.
Professional practice or medical entity: which section applies to you
Chapter 5 (§ 62) describes the records of a physiotherapist providing services within a professional practice. In that case you keep:
- internal records in the form of the individual physiotherapy care record,
- external records in the form of certificates, rulings or opinions, and other documents prepared on request.
You start the record when you provide the first service to the patient (§ 62(3)). Its scope is set by the reference to § 49(4).
There is one exception. It applies to a physiotherapist who practises only inside a medical facility under a contract with the entity that runs it. That person makes entries in the records kept by the entity, under the rules in chapter 2 (§ 62(2)). So the legal form you choose affects which section you apply. We describe the differences between a practice and a medical entity in the article on the legal form of a physiotherapy practice.
What the record must contain under § 49(4)
The record contains the data from subsection 3 (the patient's sequence number on the list, name, PESEL or identity document details, date and type of treatment) and also:
- the diagnosis of the disease, health problem or injury, information on past and coexisting conditions, and a description of the patient's functioning,
- data on the physiotherapy management and how it was carried out,
- a description of the health services provided,
- recommendations,
- information on rulings, opinions or certificates issued,
- information on medical devices ordered by the physiotherapist,
- the date of the entry,
- the identification of the physiotherapist providing the service.
General requirements apply on top of that. You enter the diagnosis using the International Classification of Diseases and Health Problems (§ 7(1)), and you describe functioning with reference to the International Classification of Functioning, Disability and Health (§ 7(2)). The identification of the person providing services means name, professional title, the number of the right to practise (if one has been assigned) and signature (§ 10(3)). For a detailed description of the fields, see our article on the patient record in physiotherapy.
Paper or electronic: § 1 and § 4
The wording of § 1(1) is clear: records are kept in electronic form. Subsection 2 allows paper in two cases: where a provision of the regulation says so, or where organizational and technical conditions make electronic records impossible. The regulation does not explain what exactly the second condition means. We did not check how the authorities read it, so if you rely on the exception, write down your reasons and discuss them with a lawyer.
Two points that are easy to miss:
- You keep one document in one form. Subsection 3 says that a document kept in electronic or paper form cannot also be kept in the other.
- Paper has its own rules. Pages are numbered and form a chronologically ordered whole (§ 6(1)), entries are legible and in chronological order (§ 4(1)), and the records carry a handwritten signature (§ 4(5)).
Choosing software for your records is a separate topic. We cover the criteria in the article on choosing EDM software and the basics in the text on electronic medical records in physiotherapy.
Changes to the medical records regulation in 2025-2026
The announcement of 4 September 2026 takes four amendments into account. Two matter for a practice, but check all of them.
| Amendment | In force from | What it concerns | Practice |
|---|---|---|---|
| Regulation of 9 July 2025 (Journal of Laws 2025 item 931) | 14 days after publication | From the transitional provision it appears to concern emergency medical service records | Unlikely |
| Regulation of 19 December 2025 (Journal of Laws 2025 item 1853) | 1 January 2026 | § 7(1), § 9(2) (referrals), § 10(1) (identification of the entity), and hospital provisions | Yes |
| Regulation of 8 June 2026 (Journal of Laws 2026 item 758) | 26 June 2026 | § 70(4): an extract when records are disclosed after the adoption of a child | Narrowly |
| Regulation of 29 June 2026 (Journal of Laws 2026 item 876) | 1 July 2026 | Hospital services lasting up to 12 hours | No |
What does the December 2025 change mean in practice? First, referrals (§ 9(2)) now have a list of required elements, including the number of the NFZ (National Health Fund) contract under which the referral was issued. Second, § 10(1) in its new wording lists the entity's data: name and address, the departmental code and details of the medical facility (if applicable), a telephone number or e-mail address. We did not compare the previous wording point by point, so we cannot say which field is new. The safest course is to check your own record header against the current text.
The transitional provision concerns referrals. Those issued before 1 January 2026 remain valid, and until 30 June 2026 they could still be issued under the old rules. From 1 July 2026 the transitional period is over. We did not find a transitional provision for patient records created earlier. On how to organize cooperation with doctors, see our article on referrals.
Beware of the name "patient card"
From 1 July 2026 the Act on Patient Rights contains Article 30b. It describes the "patient card" (karta pacjenta) as a document generated by the Medical Information System, with basic data such as allergies or vaccinations. This is not your individual physiotherapy care record. The names sound alike, but the documents are different.
What to check at your practice after the amendment
A checklist to go through with your printed record and the templates you use:
- The header of the record and printouts contains the entity data from § 10(1) (to the extent that applies to you).
- The diagnosis is entered with the classification (§ 7(1)), and the description of functioning takes the ICF classification into account (§ 7(2)).
- Referrals that you issue or accept meet § 9(2).
- Patient statements made outside the Internet Patient Account are in the records, and the patient has been told they can also make them through the account (§ 8).
- Printouts of records are confirmed by an authorized person, who gives their name, position and signature, and when paper is handed over a copy or transcript stays with you (§ 70(2)-(3)).
- A refusal of disclosure is made in electronic or paper form, always with the reason (§ 71).
What the regulation does not cover
Looking for the retention period? It is not here. It comes from Article 29 of the Act on Patient Rights: as a rule 20 years from the end of the calendar year of the last entry, with exceptions. Fees for copies are not here either; they are in Article 28 of the Act. We discuss retention rules in the article on archiving medical records, and correcting errors in entries in a separate text: how to correct an error in medical records.
Frequently asked questions
Does the medical records regulation apply to a physiotherapist in a professional practice?
Yes. Chapter 5 (§ 62) is devoted to the records of a physiotherapist providing services within a professional practice. You keep the individual physiotherapy care record and external records in the form of certificates, rulings and opinions. The general rules in chapter 1 always apply.
Can I keep the patient record on paper?
The rule is electronic form (§ 1(1)). Paper is allowed where a provision of the regulation says so or where organizational and technical conditions make electronic records impossible (§ 1(2)). If you use this exception, write down your reasons. We did not check how inspection bodies assess this condition.
Does the regulation include a ready-made template of the physiotherapy record?
In the consolidated text we did not find a graphic template of this record. The annexes concern assessment criteria for pregnancy and births, the pregnancy record and the child health booklet. For a physiotherapist the regulation sets the scope of the record (§ 49(4)), and the layout is up to you.
After the 2026 changes, do I have to replace all my records?
The transitional provision concerns referrals only: those issued before 1 January 2026 remain valid. The regulation says nothing separate about records created earlier. Check that the template you use from now on covers the elements in § 7, § 10 and § 49(4).
Where can I check the current text of the regulation?
In the Journal of Laws, through the European Legislation Identifier. Before you rely on it, check that no further amendment or new consolidated text has been published after 4 September 2026.
Legal status as of: 2 November 2026
Legal basis: Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (consolidated text Journal of Laws 2026 item 1391), §§ 1, 2, 4, 6-11, 49, 62, 69-71 and annexes; amending regulations: Journal of Laws 2025 items 931 and 1853 and Journal of Laws 2026 items 758 and 876 (to the extent indicated in the announcement); Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman (consolidated text Journal of Laws 2024 item 581, as amended by Journal of Laws 2026 items 26 and 791), Articles 28, 29 and 30b. We did not check: the full text of the regulation of 9 July 2025, the previous wording of § 7 and § 10(1), the interpretation by inspection bodies of the exception to electronic form, or the implementing provisions to the Act on the Health Care Information System.
Last reviewed: 2 November 2026
The TARCZA package contains instructions and a template for the patient record, a therapy plan, a treatment log, a treatment consent and rules on storing records, organized around the provisions described in this article. The documents do not replace legal advice and do not guarantee the outcome of an inspection. See the TARCZA package or compare packages.
Related articles:
- Medical records in physiotherapy
- The patient record in physiotherapy: template and fields
- EDM in physiotherapy
- How to correct an error in medical records