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What is all the fuss about Patient Note Keeping?

Why is patient record keeping so important?

Accurate record-keeping by health care practitioners is essential as records become important evidence in the event of a payment dispute, complaint or a legal case. In addition, the detail and accuracy are important if the treating practitioner, or another practitioner, have to refer back to the notes at a later stage to understand the patient’s medical history.

What is a patient record?

A health record may be 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.

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.

What constitutes a Health Record?

  • Hand-written or electronic notes taken by the health care practitioner

  • Notes taken by previous practitioners attending 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 races, etc

  • Audio-visual 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

How long should I retain my patient records?

  • Records should be kept for at least 6 years after they become dormant

  • The records of minors should be kept until their 21st birthday

  • The records of patients who are mentally impaired should be kept until the patient’s death.

  • Records pertaining to illness or accident arising from a person’s occupation should be kept for 20 years after treatment has ended

  • Records kept in provincial hospitals and clinics should only be destroyed with the authorization of the Deputy Director-General concerned

What must my patient records include?

  • According to the HPCSA the following is the basic patient information requirements for a patient record:

  • Personal (identifying) particulars of the patient.

  • The bio-psychosocial 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 or telephonic consent from next of kin if patient is unable to give consent.