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.