Some examples of health records include: hand-written notes taken by a healthcare practitioner, patient discharge summaries, referral letters to and from other healthcare practitioners, laboratory reports and evidence, audio-visual records such as photographs and videos, clinical research forms and clinical trial data, death certificates and autopsy reports, and any other form which may need to be completed during the interaction between the healthcare practitioner and his or her patient.
There are a number of reasons why health records should be retained and many practitioners question how long these records should be kept for. According to the HPCSA’s Guidelines, health records should be stored for a period of not less than 6 years as from the date they become dormant.
There are certain exceptions to this rule which need to be noted. For minors, health care practitioners should keep health records until the minor reaches 21 years of age so that the minor has a period of 3 years, after turning 18 years old, to bring a claim. This rule extends to obstetric records. For those patients who are mentally incompetent, health records should be kept for the duration of the patient’s lifetime.
A further exception applies to those patients treated in terms of the Occupational Health and Safety Act (Act No. 85 of 1993). Health records for these patients must be kept for a period of 20 years after treatment.
It is important to note that a number of other factors may require health records to be kept for longer periods, but no clear-cut rules exist in this regard. For example, some health conditions take a longer period to develop, and records of patients who may have been exposed to these conditions, should be kept for a sufficient period of time. For these cases, the HPCSA recommends retaining the records for a period of 25 years. Healthcare practitioners should always comply with statutory obligations prescribing periods for which patient records should be retained.