Your organisation might have set standards that you are expected to meet regarding the content and structure of medical records. If not, or if you are in private practice, you should refer to guidance developed by relevant professional bodies and associations in South Africa.
Alternatively, you might find it useful to refer to national standards set in other countries (see the Resources section). While there are variations between them, all published standards share the following features:
- All continuation sheets for progress notes should be labelled with the patient’s name and at least one other form of identification, such as a hospital number.
- Entries and reports should be kept in chronological order.
- Entries in the notes should be legible and signed, with the name and designation of the author printed in block capitals, along with the date and time.
- An entry should be made in the medical record on each occasion that a patient is seen by a doctor. In the case of hospital patients, the patient should be seen by a doctor a specified minimum number of times a week.
- Each record entry should identify the most senior clinician present at the time
Abbreviations are commonly used in medical records but can be misinterpreted and lead to mistakes in diagnosis or management. So the rule is, when in doubt, write it out – in full. Sarcastic and derogatory abbreviations have no place in medical records – acronyms like FAS (Fat and Stupid) are gratuitously offensive and sure to destroy any therapeutic relationship if the patient discovers their meaning.
Section 10 of the National Health Act 2003 states that all healthcare providers must supply patients with discharge reports. At the bare minimum, these should contain the following information:
- The health service rendered
- The patient’s prognosis
- The need for follow-up treatment.
It is also advisable to include information about medication and any relevant warnings and advice for the patient and/or the patient’s GP.
Good records management makes everybody’s life easier and facilitates continuity of care, reducing the risk of adverse incidents through misplaced or untraceable records. Problems with medical records – lack of accessibility, poor-quality information, misinformation, poorly organised notes, mis-filing, and many others – are known to lie at the root of a high proportion of adverse incidents.
For the sake of efficiency and safe practice, every healthcare organisation should have a records management policy in place, and this should be regularly reviewed and updated to keep pace with technological advances and legislative requirements. The international standard for records management - ISO/IEC 15489:2001 – Information and Documentation: Records Management – has been adopted as a national standard in South Africa (SANS 15489:2004) and can be purchased from the South African Bureau of Standards (see the Resources section). The legislative requirements for an acceptable records management policy are broadly set out in sections 19(1) and (2) of the Protection of Personal Information Act No 4 of 2013.