Medical records are the document that explains all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress, and medication. If written correctly, notes will support the doctor about the correctness of treatment.
Below is How To Obtain Medical Records In South Africa
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 computerized 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 unauthorized 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 the illegibility of handwritten notes, failing to date and sign them, inaccurate recording of information, or insufficient detail.
Can I request my medical records from South Africa?
In terms of the Promotion of Access to Information Act, 2000 everyone has the right of access (request access) to records which includes access to their healthcare/medical records.
The exception, however, is where a patient pays for a copy of his/her medical records.
How long are medical records kept in South Africa?
The HPCSA offers the following guidance on the retention of medical records: Records should be kept for at least 6 years after they become dormant. The records of minors should be kept until their 21st birthday. The records of patients who are mentally impaired should be kept until the patient’s death.