UNIT 14
Medical Records
The importance of medical records:
A medical record is an important link in the doctor-patient relationship
It’s not a legal requirement but its essential that comprehensive and accurate records be kept
The council for health professions in SA regards it as unethical to neglect to keep records
This applies to all doctors, irrespective of whether they work in private or state hospitals
These records may serve as the only evidence if a doctor is accused of negligent malpractice
Medical records are also important to patients not only with regards to health care but also
employment, insurance and litigation
Information that must be included in medical records:
1. Personal particulars of the patient
2. Medical history of the patient
3. Time, date and place of every consultation
4. Diagnosis of the patient’s condition
5. Treatment and advise given to the patient
6. Medicines and dosages prescribed
7. Referrals to specialists
8. Patients reactions to treatment, counter-reactions and allergies
9. Result of tests
10. Written proof of informed consent if applicable
11. Conclusions, preliminary diagnoses, relates diagnoses, clinical synopsis and post mortem report
Information that must NOT be included in medical records:
1. Sometimes sensitive and non-relevant information is included in the records and are prejudicial to the
interests of the patient
2. Its inappropriate to include personal criticism like saying the patient is fat and clumsy in the medical
record
3. Its recommended that factual information on patients should be included rather than conclusions and
observations
Safekeeping of medical records:
Its important that medical records be filed carefully and stored in a safe place
Claims based on negligent malpractice excluding complaints lodged with the council for health
professions of SA and criminal complaints expire 3 years after the events
1
, This period commences on the date the complainant is informed of the event or the date on which
knowledge can be obtained = so its essential that records be kept as long as possible
Council for health professions of SA recommendations:
They recommend that medical records be kept for 6 to 9 years
Provision should be made for persons who are non compos mentis = the prescription term for claims of
persons who are in this mental state commences when the disability is resolved
Provisions must also be made for persons below 18 (minors) unless they are married
Minors period of prescription expires 3 years from the date they attained majority = this means the date
they turned 18 years then they have 3 years at their disposal to enforce a potential civil claim against
another person
Its recommended that records be kept until the person has reached a full age of 24 years
If a doctor sells his practice then he must ensure access to the records for himself and his legal
representative
Amendment to medical records:
Amendments must not be effected lightly
Amendment may create an impression of negligence and should only be made if absolutely necessary
Should amendments be necessary they must be accompanied by the signature of the doctor concerned
and the date it was effected
They should be accompanied by a note explaining why they were made
If a patient requests that an amendment be made but the doctor doesn’t agree then the patients version
should be added to the record
Secrecy of medical records:
The information contained in medical records is confidential and should be kept a secret
The basis for this is enshrined in the Hippocratic oath, declaration of Geneva, International code of
medical ethics and Rule 16 of the council for health professions of SA
There is a professional obligation to secrecy and neglecting this obligation might lead to an action for
violation of privacy, defamation of character or breach of contract
Professional confidentiality:
The ethical rules of the council says that no medical practitioner may disclose any essential information
regarding a patient’s health without the patient’s express consent
In the case of the minor = without his parent/guardian
In the case of a deceased patient = without his next of kin or executor of his estate
Patient claims medical records:
If the patient’s claim to access his medical records is investigated then stipulations of the constitution
apply
S 32(1) = Everyone has the right of access to any information held by the state
State hospitals and the doctors that work in them are obliged to allow patients access to their medical
records
Only essential information to exercise/protect rights must be released
2
Medical Records
The importance of medical records:
A medical record is an important link in the doctor-patient relationship
It’s not a legal requirement but its essential that comprehensive and accurate records be kept
The council for health professions in SA regards it as unethical to neglect to keep records
This applies to all doctors, irrespective of whether they work in private or state hospitals
These records may serve as the only evidence if a doctor is accused of negligent malpractice
Medical records are also important to patients not only with regards to health care but also
employment, insurance and litigation
Information that must be included in medical records:
1. Personal particulars of the patient
2. Medical history of the patient
3. Time, date and place of every consultation
4. Diagnosis of the patient’s condition
5. Treatment and advise given to the patient
6. Medicines and dosages prescribed
7. Referrals to specialists
8. Patients reactions to treatment, counter-reactions and allergies
9. Result of tests
10. Written proof of informed consent if applicable
11. Conclusions, preliminary diagnoses, relates diagnoses, clinical synopsis and post mortem report
Information that must NOT be included in medical records:
1. Sometimes sensitive and non-relevant information is included in the records and are prejudicial to the
interests of the patient
2. Its inappropriate to include personal criticism like saying the patient is fat and clumsy in the medical
record
3. Its recommended that factual information on patients should be included rather than conclusions and
observations
Safekeeping of medical records:
Its important that medical records be filed carefully and stored in a safe place
Claims based on negligent malpractice excluding complaints lodged with the council for health
professions of SA and criminal complaints expire 3 years after the events
1
, This period commences on the date the complainant is informed of the event or the date on which
knowledge can be obtained = so its essential that records be kept as long as possible
Council for health professions of SA recommendations:
They recommend that medical records be kept for 6 to 9 years
Provision should be made for persons who are non compos mentis = the prescription term for claims of
persons who are in this mental state commences when the disability is resolved
Provisions must also be made for persons below 18 (minors) unless they are married
Minors period of prescription expires 3 years from the date they attained majority = this means the date
they turned 18 years then they have 3 years at their disposal to enforce a potential civil claim against
another person
Its recommended that records be kept until the person has reached a full age of 24 years
If a doctor sells his practice then he must ensure access to the records for himself and his legal
representative
Amendment to medical records:
Amendments must not be effected lightly
Amendment may create an impression of negligence and should only be made if absolutely necessary
Should amendments be necessary they must be accompanied by the signature of the doctor concerned
and the date it was effected
They should be accompanied by a note explaining why they were made
If a patient requests that an amendment be made but the doctor doesn’t agree then the patients version
should be added to the record
Secrecy of medical records:
The information contained in medical records is confidential and should be kept a secret
The basis for this is enshrined in the Hippocratic oath, declaration of Geneva, International code of
medical ethics and Rule 16 of the council for health professions of SA
There is a professional obligation to secrecy and neglecting this obligation might lead to an action for
violation of privacy, defamation of character or breach of contract
Professional confidentiality:
The ethical rules of the council says that no medical practitioner may disclose any essential information
regarding a patient’s health without the patient’s express consent
In the case of the minor = without his parent/guardian
In the case of a deceased patient = without his next of kin or executor of his estate
Patient claims medical records:
If the patient’s claim to access his medical records is investigated then stipulations of the constitution
apply
S 32(1) = Everyone has the right of access to any information held by the state
State hospitals and the doctors that work in them are obliged to allow patients access to their medical
records
Only essential information to exercise/protect rights must be released
2
