THE IMPORTANCE OF KEEPING PROPER PATIENT RECORDS
The Health Professions Council of South Africa places “health care practitioners” – i.e. persons registered with the HPCSA – under an obligation to keep proper medical records. The HPCSA has published Guidelines on the Keeping of Patient Records (HPCSA) Pretoria (2008), and compliance with these Guidelines is critical for both continuity of patient care and for defending complaints or negligence claims.
A health record is defined as “any relevant record made by a health care practitioner at the time of or subsequent to a consultation and / or examination or the application of health management”, and contains the information about the health of an identifiable individual recorded by a health care professional, either personally or at his or her direction.
The following documents are regarded as the essential components of a health record, depending on the nature of the individual case:
· Hand-written contemporaneous notes taken by the health care practitioner;
· Notes taken by previous practitioners attending to health care or other health care practitioners, including a typed patient discharge summary or summaries;
· Referral letters to and from other health care practitioners;
· Laboratory reports and other laboratory evidence such as histology sections, cytology slides and printouts from automated analysers, X-ray films and reports, ECG traces, etc;
· Audiovisual records such as photographs, videos and tape-recordings;
· Clinical research forms and clinical trial data;
· Other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty;
· Death certificates and autopsy reports.
The HPCSA requires that the following minimum information be included in a patient’s medical record:
· Personal (identifying) particulars of the patient;
· The biological, psychological and social history of the patient, including allergies and idiosyncrasies;
· The time, date and place of every consultation;
· The assessment of the patient’s condition;
· The proposed clinical management of the patient;
· The medication and dosage prescribed;
· Details of referrals to specialists, if any;
· The patient’s reaction to treatment or medication, including adverse effects;
· Test results;
· Imaging investigation results;
· Information on the times that the patient was booked off from work and the relevant reasons;
· Written proof of informed consent, where applicable.
Medical records must be objective recordings of what a health care practitioner has been told or discovered through investigation or examination, must be clear and legible, made contemporaneously and signed and dated. The records should be stored securely for a period of not less than six (6) years from the date on which they become dormant.
The HPCSA further requires that records should be complete, but concise. Self-serving or disapproving comments should be avoided in patient records (facts and drawn conclusions which are essential for patient care should be recorded).
Adherence to the Guidelines can make all the difference with regard to a clinical negligence claim being successfully defended, and all health care practitioners should ensure that they are familiar with the contents of the Guidelines.