The meaning of a “longitudinal collection” is not defined, but points to a focus on continuity. The primary purpose of patient health records is to serve as a reminder of what has been done or found, and to provide evidence of the standard of care.
Content of a patient health record
A practitioner must include all clinical findings in a record. Where a patient was examined, diagnosed and treated by a multidisciplinary team of practitioners, the record must include who made a specific notation.
A record must include the times of consultations and other clinical interactions such as WhatsApp messages, the patient’s clinical history, details of the clinical examination, any differential diagnoses, information and advice given to the patient, clinical decisions made (as well as who made these decisions and when), decisions and actions agreed to by the patient, treatment administered, drugs and dosage prescribed, details of investigations ordered and results received, as well as any follow-up appointments or referrals.
A practitioner must record face-to-face discussions with the patient and all progress notes when a patient is consulted for a review, for example, while a patient is hospitalised. Records of virtual, telephonic or similar discussions, any consultations with the patient’s relatives, discussions with the practitioner’s colleagues, and all correspondence related to patient care must be made and retained.
Rules relating to patient health records
Records must be accurate, contemporaneous, have integrity, be attributable, easily accessible, and stored securely. All records must be complete, comprehensive, clear, legible, unambiguous, checked regularly, in order, and each page must identify the patient. Each note must be signed in full, and a practitioner’s name must be included in block letters.
Alteration of patient health records
Retrospective notes must state the reasons for the late recording, must be dated, and signed in full. Where records are in electronic format, the identity of the person effecting a change must be recorded together with the reason for the amendment.
Retention of patient health records
Practitioners are encouraged to strike a balance between the costs of a record’s indefinite retention and the risk of mounting an inadequate defence to a costly negligence claim.
Records should be stored for a minimum of six years, although ideally records should be stored indefinitely. Practitioners must use their discretion in deciding whether to retain records of certain patients for a longer period. For example, if a patient experienced a particularly difficult labour in delivering her child, the records should be kept for a longer duration.
Records of minors should be retained until at least the minor’s 19th birthday, as minors have one year after reaching majority to institute a claim. The records of a mentally incapacitated person should be kept for the duration of that patient’s lifetime, or where a person suffers from a temporary mental incapacity, for one year after the person has recovered.
Where statutory obligations require longer retention periods, a practitioner must comply with these obligations. For example, any records falling under the Occupational Health and Safety Act, 1993 must be retained for 20 years after treatment.
Records kept in a provincial hospital or clinic may only be destroyed if the relevant Deputy Director-General authorises their destruction.
Access to health information and to patient health records
Practitioners must issue a written discharge report to a patient on discharge from a healthcare establishment. Out-patients may be discharged orally.
Patients over the age of 12 must be given access to their records on request. Access to a third party should only be given with the child’s written authorisation, although parents or guardians may submit a request under the Promotion of Access to Information Act, 2000, to access the records of children under the age of 16. Information about termination of pregnancy may not, without the patient’s consent, be divulged to any party other than the patient, regardless of the patient’s age.
A practitioner may only grant access to records without the patient’s authorisation if a court orders its release, where a practitioner requires access in order to mount a defence to a negligence claim or HPCSA disciplinary proceedings, where the practitioner is under a statutory obligation to disclose certain medical facts, or where non-disclosure would present a serious risk to public health.
Privacy and security of patient health records
Privacy and security are crucial in order to comply with the Protection of Personal Information Act, 2013. POPIA provides that practitioners may process special personal information such as religious beliefs, race, health or sexual relationships, and biometric information if the information is necessary for the patient’s proper treatment and care, or for the practice’s administration. Given the nature of this information, practitioners must obtain specific written consent when gathering this information and ensure that it is kept confidential. A patient’s personal information should be de-identified if published, and anonymity should always take preference.
In terms of the National Health Act, 2003, the person in charge of a healthcare establishment in possession of health records must set up control measures to prevent unauthorised access to the records or the storage facility or system in which records are kept. This applies to both hard copy and electronic records. Storage facilities must have secure, and restricted access control, and electronic data must be managed, stored and backed up using internationally accepted standards. Healthcare practitioners must ensure protection of patient confidentiality during electronic data transmission and when documents are being transferred between facilities or practitioners.
Practitioners are encouraged to read POPIA in conjunction with all HPCSA’s guidelines, rules and regulations.
The importance of proper recordkeeping
While patient recordkeeping may appear to be a tedious and time-consuming task, its importance cannot be understated as the revised Guidelines state that patient healthcare records “form an integral part of the standards of professional conduct against which a complaint of professional misconduct will be evaluated”. See R B v Smith (211/2018) [2019] ZASCA 48, which highlights the importance of keeping clearly and accurately written patient records
Practitioners should take all practical steps to familiarise themselves with the HPCSA guidelines and POPIA.
Training and workshops should be held so that practitioners, including practice managers, administrative, accounts, nursing and reception staff are kept abreast of all developments in the law.
