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To be useful, the medical records should contain all the significant information that members of the healthcare team, or future carers, will need in order to be sufficiently informed about the patient’s past and current clinical assessments and treatment and relevant family and social history, lifestyle and beliefs. The HPCSA considers the contents listed in Box 2 as the absolute minimum necessary for each patient’s records.

To this we would add, from a medicolegal and risk-management perspective:

  • All important positive and negative findings from the consultation with the patient. Information about the presence or absence of certain signs or symptoms at different stages in the course of a patient’s illness is not only important for forming a picture of the development of the patient’s condition, but can be crucial in defending any future medicolegal challenges (see Box 3).
  • Differential diagnosis, including reasons for ruling out (or preferring) a potential diagnosis.
  • Details of discussions with the patient about the risks and benefits of proposed treatments, including the risks of no treatment, costs and any information given to them in this regard (eg, patient information leaflets).
  • Any advice or warnings given to the patient – not to drive while taking certain medication, for example.
  • Arrangements for follow-up tests, future appointments and referrals made.
  • Any instructions or advice given to the patient. It is particularly important to make a note of any instructions you give to patients about what to do if their symptoms change, persist or worsen, such as returning for another consultation.

Box 2: Compulsory elements of clinical records

The HPCSA specifies the following minimum information that should be included in a patient’s clinical record:

  • Personal (identifying) particulars of the patient.
  • The bio-psychosocial 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 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.

HPCSA, Guidelines on the Keeping of Patient Records (2008), para 4.

Box 3: The importance of recording findings

An analysis of MPS cases arising from missed diagnosis of meningitis found that, in many of the cases in the sample, the patient was seen by a series of doctors before a diagnosis was made. This can make it difficult to assess the progress of the patient’s illness, so good note taking is crucial. Few of the notes in the sample recorded the patient’s temperature, pulse rate or a description of the patient’s awareness levels. Moreover, they often omitted the negative findings of clinical examinations.

Anthony, S. Don’t Get Caught in the Rash Trap, MPS Casebook 14(1): 25 (2006).