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:
- Definition of a patient health record
- Purpose of patient health records
- Content of patient health records
- Rules related to patient health records
- Alteration of patient health records
- Privacy and security of patient health records
- Retention of patient health records
- Ownership of patient health records
- Access to health information and to patient health records
- Checklist for patient health record keeping
- Signing of official documents
- Certificates and reports
- Issuing of prescriptions
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Revised recordkeeping guidelines_10 Nov 2022
