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.

What is so important about signatures?

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

What to do if you must alter a patient record?

It is vital to remember that no information or entry may ever be removed from a health record. Should an error or incorrect entry be discovered in a record it 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. Any additional entries added at a later date must be dated and signed in full and the reason for an amendment or error should also be specified on the record.

Is consent really that important?

An informed consent form can go a long away in assisting a practitioner to prove what the patient was aware of, in and during the consultation.

An informed consent form will also assist in showing that a patient was made aware of the aspects of their treatment. A court of law takes cognisance of the documents signed by a patient when they allege that they were not made aware of aspects of their treatment. The most practical answer is to have standardised forms developed specifically for your practice which cover the procedures that patients will undergo. On signing these forms; patients acknowledge that they have read and understood the contents of the informed consent, thereby protecting the practitioner and focusing the patient’s attention on ensuring that they really do understand their treatment.

Here are our top 10 tips for patient records

Records should be legible and complete, but concise
Records should be consistent.
Record must be date and time stamped with a signature
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)
A standardised format should be used (e.g. notes should contain in order the history, physical findings, investigations, diagnosis, treatment and outcome.).
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.
Copies of records should only be released after receiving proper authorisation.
Billing records should be kept separate from patient care records.
Attached documents such as diagrams, laboratory results, photographs, charts, etc. should always be labelled. Sheets of paper should not be identified simply by being bound or stapled together – each individual sheet should be labelled
Always get consent!

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