Guidelines on the keeping of patient records

Practitioners belonging to the Medical and Dental Board are advised to comply with the HPCSA Guidelines on Keeping of Patient Records.

The HPCSA Inspectorate Office recently lent their assistance to a joint operation by the Road Traffic Management Corporation’s Anti-Corruption Unit and the Directorate for Priority Crime Investigation looking into possible fraud and corruption in the issuing of Professional Driving Permits to members of the public.

The investigations revealed that the majority of Medical Practitioners do not have proper records of the patients for whom they completed medical certificates for PDPs, contrary to HPCSA guidelines which prescribes that a health record is defined as information about the health of an identifiable individual recorded by a healthcare professional either personally or at his or her direction.

In guiding the profession, the Practice Committee of the Medical and Dental Professions Board remind practitioners on the importance of compliance to Guidelines on the Keeping of Patient Records (Booklet 9) resulting in penalties in event of non-compliance.

For more information contact the Practice Committee of the Medical and Dental Board.