It seems that the HPCSA is placing greater relevance on the documentation that doctors use in their everyday clinical work.
Medical Protection has seen correspondence that the HPCSA is sending to doctors when requesting a response to patients’ complaints to the regulator. This correspondence places a greater emphasis on providing the HPCSA with specific pieces of documentation as part of the investigation.
This documentation requirement includes those cases involving issues with billing or fees – with doctors now expected to provide copies of any cost estimates given to patients, together with the informed financial consent from patients and a statement of account issued to patients in terms of section 53 of the Health Professions Act.
The HPCSA correspondence adds: “Matters related to the clinical treatment of the patient should be accompanied by the relevant clinical notes for the encounter complained about and consent forms where relevant.”
Over the years, Medical Protection has repeatedly emphasised the importance of good record-keeping – and you can read more here about the vital role it plays in dealing with complaints and claims.