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".
It contains the information about the health of an identifiable individual recorded by a health care professional, either personally or at his or her direction.
Keeping good medical records forms and integral part of delivering high-quality, evidence-based healthcare.
What is regarded as a medical record?
The following documents are all regarded as medical records. The form and content of the document will depend on the nature of the individual case.
- Hand-written contemporaneous notes taken by the health care practitioner;
- Clinical notes made by previous attending health care practitioners;
- Referral letters to and from other health care practitioners;
- Laboratory findings including haematology, cytology and histology reports;
- X-ray, scan and sonar reports, films and tracings ie: ECG print-outs;
- 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 claim forms, disability assessments and documentation related to injuries on duty;
- Death certificates and autopsy reports.
What information should be included in a medical record?
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 a specialists, if any;
- The patient's reaction to treatment or medication, including any adverse effects;
- Test results;
- Imaging investigation results;
- Information regarding occasions 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 observed through investigation and physical examination.
The records must be clear, concise and legible, made contemporaneously, signed and dated.
Management of health care records
Many health care practitioners are unaware of how to manage medical records and do not know when it is permissible to dispose of them.
Good records management is essential for the continuity of care of your patients, and can reduce the risk of adverse incidents through misplaced or untraceable records.
The HPCSA offers the following guidance on the retention of medical records:
- Records should be kept for at least six 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 for the duration of their lifetime.
- According to the Occupational Health and Safety Act 85 of 1993 (OHSA), records pertaining to illness or accidents arising from a person’s occupation should be kept for 20 years after treatment has ended and such periods should be extended if there are specific reasons for doing so, such as when a patient has been exposed to conditions that might manifest in a slow-developing disease, such as asbestosis.
- Records kept in provincial hospitals and clinics should only be destroyed with the authorisation of the Deputy Director-General concerned.
- The cost and space implications of keeping records indefinitely must be balanced against the possibility that records will be found useful in the defence of litigation or for academic or research purposes.
Adherence to the above-mentioned principles and guidelines can make all the difference with regard to a potential clinical negligence claim being successfully defended, and all health care practitioners should ensure that they are familiar with the Statutory requirements governing their profession.
