Legal Insight- How long should you keep your patients records for?

By Roxann Van Rugge 1 year ago
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A health record is defined as any relevant record which is made by a healthcare practitioner during or after a consultation and/or examination with a patient. A health record may also come about as a result of the application of health management. These records are made up of identifiable health information about an individual, which is personally recorded by a healthcare practitioner. The information may also be recorded at the request of the individual.

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.

All practices should aim to strike a balance between the costs of indefinite retention of records and the likelihood that a healthcare practitioners’ defence against a case of negligence would be affected by the absence of records. Other factors to consider are the value of the record for academic or research purposes, and the risks resulting from the handling or complications of the case.

To learn more:
Next Biosciences will be hosting 4 Ethics CPD Events in 2018:
Tuesday 20th February- POPI and Your Medical Practice
Tuesday 8th May- Patient Confidentiality and Record-Keeping Regulations
Tuesday 17th July- Ethical Guidelines for Reproductive Health
Tuesday 18th September- The Responsibilities of Healthcare Practitioners to HIV Positive Patients.
Reserve your seat and earn 2 ethics points per event. Please send an email to rsvp@nextbio.co.za.
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 Roxann Van Rugge

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