The Privacy of Patient Records: Dr Cobus van Niekerk reports on the guidelines
In pursuit of high-quality clinical outcomes and mutual trust between healthcare practitioners and patients, the Health Professions Council of South Africa (HPCSA) has recently revised the guidelines for patient recordkeeping. These guidelines offer a framework to ensure ethical and efficient healthcare practices while enhancing clinical outcomes, reducing waste, and increasing stakeholder satisfaction. This article provides a condensed overview of the most crucial points and laws outlined in the updated guidelines.
The Spirit of Professional Guidelines
The HPCSA recognises that exceptional clinical outcomes are achieved when a strong bond of trust exists between healthcare practitioners and patients. Thus, the practice of healthcare is inherently ethical and requires practitioners to commit to ethical conduct and prioritize the welfare of patients and society. The HPCSA’s ethical guidelines underscore the importance of adhering to these principles, serving as a foundation for evaluating professional conduct.
Key Sections of the Revised Guidelines
- **Definition of a Patient Health Record**
A patient health record encompasses an individual’s personal and health information, recorded by a healthcare practitioner or as directed by one, regardless of the format or medium used.
- **Purpose of Patient Health Records**
The primary role of patient health records is to serve as reminders of decisions and actions, ensure continuity of care, and provide evidence of the quality of care. These records also contribute to clinical practice, audits, teaching, research, administration, legal purposes, and more.
- **Content of Patient Health Records**
Patient health records must include comprehensive clinical findings, interactions, examination details, diagnoses, treatments, medications, referrals, patient responses, investigations, and more. These records should reflect accurate, complete, and legible information to facilitate effective patient care.
- **Rules Related to Patient Health Records**
Ethical Rule 27A emphasizes that healthcare practitioners must act in the best interests of patients, maintain confidentiality, and keep accurate records. Records should be contemporaneous, maintain integrity, be attributable, accessible, and securely stored.
- **Alteration of Patient Health Records**
Late or additional entries must be dated, signed, and clearly indicated as amendments. Reasons for amendments should be specified.
- **Privacy and Security of Patient Health Records**
Health establishments must implement measures to prevent unauthorized access to patient health records, regardless of their format.
- **Retention of Patient Health Records**
Patient health records should ideally be stored indefinitely in electronic formats. If not feasible, a minimum retention period of six years after dormancy is recommended, with exceptions for minors, mentally incapacitated patients, and certain health conditions.
- **Ownership of Patient Health Records**
Healthcare practitioners or entities generating the records own patient health records. Patients are entitled to access their records, and access should be granted in cases of legal obligation, litigation, and disciplinary proceedings.
- **Access to Health Information and Patient Health Records**
Health practitioners must provide discharge reports to patients, and access to records is subject to age-specific and legal requirements. Protection of Personal Information Act (POPIA) principles apply to personal information processing, and patients’ confidentiality is a priority.
- **Checklist for Patient Health Record Keeping**
Practitioners should ensure records are complete and consistent, and avoid self-serving or derogatory comments. Standardized formats should be used, and alterations should be documented properly. Billing records must be separate from patient care records.
Conclusion
The updated HPCSA guidelines on patient record-keeping provide a comprehensive framework for ethical and effective healthcare practices. These guidelines underscore the importance of accurate, complete, and secure patient health records in promoting patient care, clinical practice, research, and education. Adherence to these guidelines will not only enhance the quality of care but also uphold the ethical standards that are fundamental to the practice of healthcare in South Africa.
References:
1. Ethical Booklet 9 – Guidelines on the keeping of patient health records – Sept 2022
2. Booklet 2 – Ethical Rules of the HPCSA.
3. Booklet 4 – Informed Consent
4. Booklet 5 – Confidentiality
5. Medicines and related Substances Control Act 101 of 1965
6. Occupational Health and Safety Act No. 85/1993
7. National Archives of South Africa Act, 1996 (Act No. 43 of 1996)
8. Choice on TOP Act 92/1996
9. Promotion of Access to Information Act, 2000 (Act No. 2 of 2000)
10. National Health Act (Act No 61/2003)
11. Children’s Act 38/2005
12. Protection of Personal Information Act 4/201
MBChB (Pret), BSCMedScHons (Stell)(Cum Laude), Advanced Dip. Aesthetic Medicine (FPD)(Cum Laude)
Dr Cobus van Niekerk is a General Practitioner with a focus on aesthetic medicine, pro-aging medicine, wellness and ethics. He is the founder of Wellnessthetics in Johannesburg, South Africa. He is also the Vice President of the Aesthetic & Anti-Aging Medicine Society of South Africa (AAMSSA), where he oversees the Medico-legal, Ethics, and Social Media portfolios.
Dr van Niekerk graduated from the University of Pretoria in 1997 and the University of Stellenbosch in 2001 with a BScMedScHons degree (Cum Laude) in Reproductive Biology. He then worked in Internal Medicine, Emergency Medicine, Trauma, and Intensive Care in the United Kingdom. He became a member of the Royal College of Surgeons of Edinburgh in 2007. Dr van Niekerk also contributes to the medical landscape as a member of the Scientific Committee of the Aesthetic Medicine Congress of South Africa (AMCSA), underscoring his commitment to fostering innovation and collaboration in Aesthetic Medicine.
Dr van Niekerk is a skilled speaker and a distinguished graduate of the Advanced Diploma of Aesthetic Medicine (ADAM), graduating cum laude. He is committed to the fields of Wellness, Aesthetics, Pro-aging, and Ethics, and he enriches the medical landscape with his expertise and dedication.