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Medical Records in South Africa: An MPS Guide

Correct as of June 2014

Medical Records SA

Summary

Keeping good medical records is essential for continuity of care, especially when many clinicians are involved in a patient’s care. Good record keeping is an integral part of good professional practice.

  • Records should include sufficient detail for someone else to take over a patient’s care, seamlessly, from where you left off.
  • Records that ensure continuity of care will also be adequate for evidential purposes, in the event of a complaint, claim or disciplinary action.
  • Medical records should be clear, objective, contemporaneous, tamper-proof and original.
  • Abbreviations, if used, must be unambiguous and understood by all members of the healthcare team.
  • Medical records comprise handwritten and computerised notes, correspondence between health professionals, laboratory reports, x-ray and other imaging records, clinical photographs, videos and other recordings, and printouts from monitoring equipment.
  • Medical records are sensitive personal data and must be kept securely to prevent damage and unauthorised access.
  • Medical records can usually be shared with other members of the clinical team responsible for clinical management, unless the patient objects.
  • Access to records or the information they contain is also permissible in other circumstances but the record holder must always be prepared to justify disclosure.
  • Where information from medical records is required for audit and research purposes, consent should be taken from the data subject to process the information for that purpose.
  • Any alteration to medical records should be patently apparent to avoid any accusation that there has been an attempt to mislead or deceive.
  • Common problems are illegibility of handwritten notes, failing to date and sign them, inaccurate recording of information or insufficient detail.