Electronic health record
It is the only document that can defend you or condemn you years after the care was provided.
An electronic health record is the chronological record of a patient’s health conditions and of the actions performed by the team caring for them, kept in digital form.
In Colombia it is not a management choice: it is a mandatory, private and confidential document, with its own rules for how it is completed, safeguarded and retained.
In short
- What it is: the mandatory record of care, with legal and evidentiary value.
- Core regulation: Resolution 1995 of 1999, amended by Resolution 839 of 2017.
- How long it is kept: fifteen years from the last encounter.
- Who can see it: only the patient, the care team and the cases provided for by law.
- What’s new: since Resolution 1888 of 2025 it is no longer enough to store it well; it also has to be able to travel.
What Colombian law requires
It is mandatory and it is private. Law 23 of 1981 defined it as the mandatory record of the patient’s health conditions, private information subject to confidentiality except with the patient’s authorization or in the cases provided for by law.
It has rules for completion. Resolution 1995 of 1999 sets how it is completed, managed, retained and safeguarded, and defines it as a private, mandatory and confidential document in which the patient’s conditions and the actions of the healthcare team are recorded chronologically.
It contains sensitive data. Under Law 1581 of 2012, health data is sensitive data. That means stricter requirements: role-based access control, an audit log, and a clear purpose for every access.
It is not corrected by deleting. A signed clinical record is not edited like a text document. Corrections are made by annotation, leaving a trace of what was corrected, when and by whom. A system that lets you overwrite a signed note without a trace is a legal problem, not a convenience.
How long it must be kept
This is the question people get wrong most often, because the answer changed.
Resolution 839 of 2017 set retention at fifteen years counted from the date of the last encounter, split as follows:
| Period | Where |
|---|---|
| First 5 years | Active archive |
| Next 10 years | Central archive |
It used to be twenty years. If your internal policy still says twenty, it is out of date.
Two important exceptions: for victims of human rights violations or serious breaches of international humanitarian law the periods double, and in cases related to crimes against humanity retention is permanent, with no possibility of disposal.
The practical consequence when choosing software: the system has to guarantee availability and readable export throughout that entire period, even if you stop being a customer. It is worth asking before you sign.
What an electronic health record should have
Beyond digitizing the paper form:
Record integrity. What is signed stays signed. Corrections are annotations with a trace, not silent edits.
Access audit. Who opened which record, when and from where. It is not an advanced feature: it is what lets you respond to a complaint about mishandled sensitive data.
Structure and coding. Diagnoses with ICD-10 and ICD-11, procedures with CUPS, medications with IUM. A free-text record cannot be reported, does not support an invoice well and does not interoperate.
Availability. Accessible throughout the entire retention period, and exportable in a readable format.
Continuity when things fail. In Colombia, connectivity fails. A system that only works online stops being useful exactly when you need to provide care.
Formats that fit the practice. A nutrition consultation, a physical therapy assessment and an orthopedic note do not record the same things. A single form forces people to write in free text whatever does not fit, and that is where the structure gets lost.
Paper and electronic: the real difference
It is not in the medium, but in what the record can do afterward.
| Paper or free text | Structured and coded | |
|---|---|---|
| Search | Manual, file by file | Immediate, by any criterion |
| Reports | Someone transcribes them | Derived from the record |
| Billing | Rebuilt by reading | Comes from what was recorded |
| Interoperability | Impossible | Native |
| Access audit | Does not exist | Traceable |
| 15-year retention | Physical space and deterioration | Backup and availability |
A clinical record digitized as free text keeps almost all the problems of paper. The real leap is not leaving paper behind: it is capturing coded data at the moment of care.
The clinical record now has to be able to travel
It is the change of recent years and the one that takes the most work.
Law 2015 of 2020 created the interoperable electronic health record. Resolution 866 of 2021 defined the relevant clinical data and the mandatory catalogs. And Resolution 1888 of 2025 adopted the digital care summary (RDA) as the document exchanged between providers, with a deadline that expired on April 15, 2026.
This does not centralize the clinical record: custody remains with the institution that provided the care. What travels is a structured summary of each encounter. The details are in electronic health record interoperability.
What matters when choosing software: if capture is in free text, there is no way to comply with this without redoing the record.
What the software that manages it needs
- Structured recording with catalogs at the point of capture, not coding after the fact.
- Integrity and correction by annotation, with no silent editing of what was signed.
- Complete access audit.
- RDA generation and lookup to meet interoperability requirements.
- Adaptable templates for each specialty, without customization breaking the coding.
- Availability and export throughout the fifteen years, and when the contract ends.
- Operation with intermittent connectivity.
- Roles and permissions that separate administrative work from clinical work.
How Omneri solves it
Omneri was built on a structured clinical record, which is the condition that reporting, invoicing and interoperability depend on.
- Coded capture with the official catalogs available while the professional documents.
- Correction by annotation, keeping the original record and its trail.
- Preconfigured, customizable templates, so each professional records what their practice requires without leaving the coded structure.
- Digital signature of clinical records.
- Access audit with the user, time and context of every access.
- RDA generated from the same record and lookup of RDAs from other providers within the patient’s record.
- Orders, prescriptions, sick leave certificates and informed consents linked to the encounter that generated them.
- Teleconsultation recorded in the same clinical record, under the framework of Law 1419 of 2010 and Resolution 2654 of 2019.
- Regulatory updates included in the service.
It works just as well for an independent professional, a private practice or an IPS (instituciones prestadoras de salud, Colombia’s healthcare provider institutions). You can request a demo.
Frequently asked questions
What is mandatory is the clinical record, in whatever medium, under Law 23 of 1981 and Resolution 1995 of 1999. What makes paper unworkable in practice is the rest of the obligations: electronic invoicing with RIPS (the individual record of services provided) as supporting documentation, and, since Resolution 1888 of 2025, generating the digital care summary. Neither can be met from a paper or free-text record.
Fifteen years from the date of the last encounter, under Resolution 839 of 2017, which amended Resolution 1995 of 1999: five in the active archive and ten in the central archive. It used to be twenty, so many internal policies are out of date. For victims of human rights violations the periods double, and for crimes against humanity retention is permanent.
Yes, but by annotation, not by deleting or overwriting. The correction is recorded as a new note that documents what was corrected, when and by whom, while keeping the original record. A system that lets you edit a signed note without a trace compromises the evidentiary value of the entire file.
The patient, the care team and the authorities in the cases provided for by law. Health data is sensitive data under Law 1581 of 2012, which requires role-based access control and an audit log. In practice, administrative staff should work with scheduling and billing without seeing the full clinical record.
They must be exportable in full and in a readable format, because the obligation to keep them for fifteen years is yours, not the vendor’s. It is the question to ask during the evaluation, not after signing: ask to see a real export of a patient file, not the promise that it exists. We cover it in how to migrate without downtime.
Yes. Omneri comes with preconfigured templates, and each professional can customize them or create new ones with the fields their practice needs. What matters is that customization does not break the structure: the fields that feed reporting, invoicing and interoperability stay coded with the official catalogs. You can adapt the form to the way you work without turning the record into free text, which is what later makes reporting impossible. And with Omni, Omneri’s AI assistant, the chart is filled in from your dictation of the visit. In addition, each specialty has its own elements available, such as the odontogram in dentistry or standardized scales in psychology.
In the same clinical record and with the same requirements as an in-person visit. Resolution 2654 of 2019, which set the parameters for telemedicine in Colombia under Law 1419 of 2010, requires telemedicine activities to be recorded by the healthcare personnel who perform them, in line with Resolution 1995 of 1999. There is no separate file for care provided remotely.
It depends on the size of the operation: how many professionals document care, how many sites there are and which modules are turned on beyond the clinical record. An independent professional and a clinic with inpatient care do not pay the same. At Omneri, sizing is done during the demo, with your real operation on the table, and that produces a specific figure instead of a range.
Tell us how your hospital or clinic runs today.
We set up a demo around your case: size, sites and critical modules.
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