Patient Records - HPCSA ethical principles and professional conduct -

As healthcare practitioners, we are aware that keeping accurate and up-to-date patient records is an integral part of patient/client consultations and maintaining professional practice. It is thus concerning that the Health Professions Council of South Africa’s 2020/21 Annual Report revealed a concerning number of complaints lodged against practitioners were related to medical records.

The HPCSA guidelines for good practice in the Healthcare Professions’ Booklet 9, specifically deals with patient records. It is very important for practitioners to familiarise themselves with the guidelines on the keeping of patient records as explained below.

Definition of a health record

“A health record is defined as any relevant record made by a healthcare practitioner at the time of or subsequent to a consultation and / or examination or the application of health management”.

Documents that are regarded as health records include
- Hand-written contemporaneous notes taken by the healthcare practitioner.
- Notes taken by previous practitioners or other healthcare practitioners, including a typed patient discharge summary or summaries.
- Referral letters to and from other healthcare practitioners.
- Laboratory reports and other laboratory evidence.
- 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.

Reasons for retaining documents or materials (health records)
- To further the diagnosis or ongoing clinical management of the patient.
- To conduct clinical audits.
- To promote teaching and research.
- To use them for administrative or other purposes.
- To provide direct evidence in litigation or for occupational disease or injury compensation purposes.
- To be used as research data.
- For historical purposes.
- To promote good clinical and laboratory practices.
- To make case reviews possible.
- To serve as the basis for accreditation.

Compulsory Information that should be included in a patient record
- Personal (identifying) particulars of the patient.
- The bio-psychosocial history of the patient, including allergies and
- 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, where applicable.

Alteration of records
- No information or entry may be removed from a health record.
- An error or incorrect entry discovered in the record may be corrected by placing a line in ink 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.
- Additional entries added at a later date must be dated and signed in full.
- The reason for an amendment or error should also be specified on the record.

Ownership of patient records
- In state institutions, where records are retained (e.g. radiographs are the property of the institution, original records and images are retained by the institution).
  - Copies must however, be made available to the patient (or referring practitioner) on request for which a reasonable fee may be charged in terms of the Promotion of Access to Information Act, No. 2 of 2000.
- In cases where patients are required to pay for records and images (e.g. private patients or patients in private hospitals) such patients must be allowed to retain such records – unless the healthcare practitioners deem it necessary to retain such records for purpose of monitoring treatment for a given period.
- Should the patient, however, require the records and / or images to further or protect an interest (e.g. such as consulting with another practitioner) he or she must be allowed to obtain the originals for these purposes.
- As the ownership of records in a multi-disciplinary practice depends on the legal structure of the practice, the governing body of such multi-disciplinary practice should ensure that these guidelines and the provisions of the Promotion of the Access to Information Act relating to health records are adhered to.
- Should a healthcare practitioner in private practice (both in a single practice and in a partnership) pass away, his or her estate, which includes the records, will be administered by the executor of the estate:
  - Should a practice be taken over by another healthcare practitioner, the executor shall carry over the records to the new healthcare professional. The new healthcare practitioner is obliged to take reasonable steps to inform all patients regarding the change in ownership and that the patient could remain with the new healthcare practitioner or could request that his or her records be transferred to another healthcare practitioner of his or her choice.
  - Should the practice not be taken over by another healthcare practitioner the executor should inform all patients in writing accordingly and transfer those records to other healthcare practitioners as requested by individual patients. The remaining files should be kept in safe keeping by the executor for a period of at least twelve (12) months with full authority to further deal with the files as he or she may deem appropriate – provided the provisions of the rules on professional confidentiality are observed.
  - Certain partnership agreements may make specific provision for the management of a deceased partner’s share in the partnership after the death of a partner and such management would include dealing with patient records.
- If healthcare practitioners in private practice decide to close their practice for whatever reason they shall within three months of closure inform all their patients in writing that:
  - The practice is being closed as from a specific date.
  - Requests may be made that records are transferred to other healthcare practitioners of their choice;
  - After the date concerned, the records will be kept in safe keeping for a period of at least twelve (12) months by an identified healthcare practitioner or health institution with full authority to deal with the files as he or she may deem appropriate, provided the provisions of the rules on professional confidentiality are observed.

Access to health records
- Practitioners should note that access to patient records should be given:
- Where a court orders the records to be handed to the third party.
- Where the third party is a healthcare practitioner who is being sued by a patient and needs access to the records to mount a defence.
- Where the third party is a healthcare practitioner who has had disciplinary proceedings instituted against him or her by the HPCSA and requires access to the records to defend himself or herself.
- Where the healthcare practitioner is under a statutory obligation to disclose certain medical facts, (e.g., reporting a case of suspected child abuse in terms of the Children’s’ Act, No. 38 of 2005).
- Where the non-disclosure of the medical information about the patient would represent a serious threat to public health (National Health Act, No. 61 of 2003). In provincial hospitals medical records must be kept under the care and control of the clinical manager. Access to such records shall be subject to compliance with the requirements of the Access to Information Act and such conditions as may be approved by the superintendent.

Storage of Health Records
- Health records should be stored in a safe place and if they are in electronic format, safeguarded by passwords.
- Health records should be stored for a period of not less than six (6) years as from the date they became dormant.
- In the case of minors and those patients who are mentally incompetent, healthcare practitioners should keep the records for a longer period:
  - For minors under the age of 18 years health records should be kept until the minor’s 21st birthday
    because legally minors have up to three years after they reach the age of 18 years to bring a claim. This would apply equally for obstetric records.
  - For mentally incompetent patients the records should be kept for the duration of the patient’s lifetime.
  - In terms of the Occupational Health and Safety Act, No. 85 of 1993 health records must be kept for a period of twenty (20) years after treatment.
- Health records kept in a provincial hospital or clinic shall only be destroyed if such destruction is authorised by the Deputy Director-General concerned.

Checklist for Health Record Keeping
- Records should be complete, but concise.
- Records should be consistent.
- 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.

Although records are meant to communicate diagnosis and patient care plans during inter-professional collaboration, practitioners should ensure that they still maintain patient confidentiality.

Practitioners are encouraged to constantly update their knowledge on patient records and keep up with the changes as part of their ongoing learning activities.

References:

Last Updated on 20 February 2023 by HPCSA Corporate Affairs

Patient Records – HPCSA ethical principles and professional conduct