Good quality medical records are an essential component of safe and effective healthcare
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time. The presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome.
What are medical records?
You are obliged by the HPCSA to keep adequate medical records. The HPCSA defines a medical record as “any relevant record made by a health care practitioner at the time of, or subsequent to, a consultation and/or examination or the application of health management”.1
Medical records cover an array of documents that are generated as a result of patient care. According to the HPCSA, these include:
2.1.1 Hand-written contemporaneous notes taken by the health care practitioner.
2.1.2 Notes taken by previous practitioners attending health care or other health care practitioners, including a typed patient discharge summary or summaries.
2.1.3 Referral letters to and from other health care practitioners.
2.1.4 Laboratory reports and other laboratory evidence such as histology sections, cytology slides and printouts from automated analysers, X-ray films and reports, ECG traces, etc.
2.1.5 Audio visual records such as photographs, videos and tape-recordings.
2.1.6 Clinical research forms and clinical trial data.
2.1.7 Other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty.
2.1.8 Death certificates and autopsy reports.2
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