HPCSA Revised Recordkeeping Guidelines
/ Health care records – November 2022

Guidelines on patient recordkeeping

by HPCSA Corporate Affairs I 10 Nov 2022

The HPCSA has updated the Guidelines on the keeping of patient records (Booklet 9). Practitioners are advised to adhere to the revised guidelines on record keeping that will also improve clinical outcomes, reduce waste, and ensure stakeholder engagement and satisfaction. The HPCSA presents the following ethical guidelines to guide and direct the practice of healthcare practitioners. These guidelines form an integral part of the standards of professional conduct against which a complaint of professional misconduct will be evaluated.

The spirit of professional guidelines

High quality clinical outcomes are only achieved if patients and healthcare practitioner trust each other explicitly. Practice in the healthcare profession is therefore a moral enterprise and demands that healthcare practitioners have a life-long commitment to sound, ethical professional practice and an unstinting dedication to the interests and wellbeing of society and their fellow human beings.

It is in this spirit, that the HPCSA formulates these ethical guidelines, to guide and direct the practice of healthcare practitioners. They apply to all persons registered with the HPCSA and are the standard against which professional conduct is evaluated.

Note: In these guidelines, “healthcare practitioner” and “healthcare professional” refers specifically to persons registered with the HPCSA.

Contents

The revised HPCSA guidelines on patient recordkeeping (Booklet 9) is divided into the following sections:

  1. Definition of a patient health record
  2. Purpose of patient health records
  3. Content of patient health records
  4. Rules related to patient health records
  5. Alteration of patient health records
  6. Privacy and security of patient health records
  7. Retention of patient health records
  8. Ownership of patient health records
  9. Access to health information and to patient health records
  10. Checklist for patient health record keeping
  11. Signing of official documents
  12. Certificates and reports
  13. Issuing of prescriptions

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