[Confidentiality and the medical record. Ethical-legal considerations]

Confidentiality is a key aspect in the relationship between health professionals and patients. It involves the cession by the patient of a reserved part of herself and the ethical principles of autonomy and non-maleficency that are closely linked to its preservation. There are also numerous legal regulations that make professional secrecy obligatory, in some cases imposing hard sanctions that are often not known about. As the medical record is the document where the relationship with the patient is recorded, it requires extraordinary protection due to the especially sensitive nature of the information it contains. It should be compulsory that the professional who works with it should know some basic aspects of the fundamental laws that regulate it in different aspects. This article reviews questions that at times are only known in the abstract, but that are contained in the legal regulations, such as ownership of the medical record, subjective annotations, its custody and rectification or who can have access to it and why.