A health record is “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”.
Medical Academic recently hosted a CPD-accredited ethics webinar on the topic ‘Medical Record Keeping: A Healthcare Practitioner’s Window of Opportunity’. You can watch the replay HERE to qualify for 1 Ethics CEU.
1. A health record contains the information about the health of an identifiable individual recorded by a health care professional, either personally or at his or her direction.
2. Essential components of a health record
2.1 Hand-written contemporaneous notes taken by the health care practitioner.
2.2 Notes taken by previous practitioners attending health care or other health care practitioners, including a typed patient discharge summary or summaries.
2.3 Referral letters to and from other health care practitioners.
2.4 Laboratory reports and other laboratory evidence such as histology sections, cytology slides and printouts from automated analysers, X-ray films and reports, ECG races, etc.
2.5 Audiovisual records such as photographs, videos and tape-recordings.
2.6 Clinical research forms and clinical trial data.
2.7 Other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty.
2.8 Death certificates and autopsy reports.
Rule 15 – HPCSA Ethical Rules
“Any student, intern or practitioner who, in the execution of his or her professional duties, signs official documents relating to patient care, such as prescriptions, certificates (excluding death certificates) patient records, hospital or other reports, shall do so by signing such document next to his or her initials and surname in block letters.”
3. Documents and materials should be retained in order to:
3.1 Further the diagnosis or ongoing clinical management of the patient;
3.2 Conduct clinical audits;
3.3 Promote teaching and research;
3.4 Be used for administrative or other purposes;
3.5 Be kept as direct evidence in litigation or for occupational disease or injury compensation purposes;
3.6 Be used as research data;
3.7 Be kept for historical purposes;
3.8 Promote good clinical and laboratory practices;
3.9 Make case reviews possible;
3.10 Serve as the basis for accreditation.
Amendments to Records
No information or entry may be removed from a health record. An error or incorrect entry discovered in the record may be corrected by placing a line through it with ink and correcting it. The date of change must be entered and the correction must be signed in full. The original record must remain intact and fully legible. Additional entries added at a later date must be dated and signed in full. The reason for an amendment or error should also be specified on the record.
4. Health care practitioners should enter and maintain at least the following information for each patient consulted:
4.1 Personal (identifying) particulars of the patient.
4.2 The bio-psychosocial history of the patient, including allergies and idiosyncrasies.
4.3 The time, date and place of every consultation.
4.4 The assessment of the patient’s condition.
4.5 The proposed clinical management of the patient.
4.6 The medication and dosage prescribed.
4.7 Details of referrals to specialists, if any.
4.8 The patient’s reaction to treatment or medication, including adverse effects.
4.9 Test results.
4.10 Imaging investigation results.
4.11 Information on the times that the patient was booked off from work and the relevant reasons.
4.12 Written proof of informed consent, where applicable.
Retaining Records (s9)
• Health records should be stored in a safe place and if they are in electronic format, safeguarded by passwords.
• Health records should be stored for a period of not less than six (6) years as from the date they became dormant.
• In the case of minors and those patients who are mentally incompetent, health care practitioners should keep the records for a longer period:
– For minors under the age of 18 years health records should be kept until the minor’s 21st birthday because legally minors have up to three years after they reach the age of 18 years to bring a claim.
– This would apply equally for obstetric records.
– For mentally incompetent patients the records should be kept for the duration of the patient’s lifetime.
• In terms of the Occupational Health and Safety Act (Act No. 85 of 1993) health records must be kept for a period of 20 years after treatment.
• Practitioners should satisfy themselves that they understand the HPCSA’s guidelines with regard to the retention of patient records on computer compact discs.
• Health records kept in a provincial hospital or clinic shall only be destroyed as authorised by the Deputy Director-General concerned.
Access to Records (s11)
• A health care practitioner shall provide any person of age 12 years and older with a copy or abstract or direct access to his or her own records regarding medical treatment on request (Children’s Act (Act No. 38 of 2005)).
• Where the patient is under the age of 16 years, the parent or legal guardian may make the application for access to the records, but such access should only be given on receipt of written authorization by the patient (Access to Information Act (Act No. 2 of 2000)).
• Information about termination of a pregnancy may not be divulged to any party, except the patient herself, regardless of the age of the patient (Choice on Termination of Pregnancy Act (Act No. 92 of 1996)).
• No health care practitioner shall make information available to any third party without the written authorisation of the patient or a court order or where nondisclosure of the information would represent a serious threat to public health (National Health Act (Act 61 of 2003)).
Checklist (an 8-point revision of your clinical notes)
1. Records should be complete, but concise.
2. Records should be consistent.
3. Self-serving or disapproving comments should be avoided in patient records. Unsolicited comments should be avoided (i.e. the facts should be described, and conclusions only essential for patient care made).
4. A standardised format should be used (e.g. notes should contain in order the history, physical findings, investigations, diagnosis, treatment and outcome.).
5. If the record needs alteration in the interests of patient care, a line in ink should be put through the original entry so that it remains legible; the alterations should be signed in full and dated; and, when possible, a new note should refer to the correction without altering the initial entry.
6. Copies of records should only be released after receiving proper authorisation.
7. Billing records should be kept separate from patient care records.
8. Attached documents such as diagrams, laboratory results, photographs, charts, etc. should always be labelled.