Medical record-keeping in South Africa : a medico-legal perspective

Abstract

Medical records are the source of medical information. The keeping of medical records is crucial to the provision of quality medical care to patients. Deficient medical records can influence patient management and the continuity of medical care, which may result in inadequate health care (College of Physicians and Surgeons of British Columbia, 2014:1; Canadian Medical Association, 2012:3; Howarth & Gillespie, 2012:2; Pirkle et al., 2012:564; Wong & Bradley, 2009:4; Mann & Williams, 2003:329). Medical records are also medico-legal documents. They are used to defend doctors against legal action and also to inform expert medical opinions in the case of medico-legal litigation. Therefore, good medical record keeping is of paramount importance (Van den Heever & Lawrenson, 2015:3; Howarth & Gillespie, 2012:2; McQuoid-Mason & Dhai, 2011:85; Shamus & Stern, 2011:110). Accurate medical record keeping is also a requirement of section 27A of the ethical and professional rules of the Health Professions Council of South Africa (HPCSA), registered under the Health Professions Act (Act No. 56 of 1974) and promulgated in Government Gazette R717/2006. According to this act, the HPCSA has to provide doctors with guidance regarding ethical and professional conduct. The guidance is provided in the form of booklets. Booklet 9 provides guidance on medical record keeping. The Medical Protection Society (MPS) is the leading protection organisation for doctors. It protects and supports their professional interests. The MPS has also published guidelines regarding medical record keeping for its members to abide by in South Africa. This study compares the medical ethical guidance documents and relevant legislation in South Africa to ascertain the extent that the medical ethical guidance documents incorporate and repeat South African legislation regarding medical record keeping. The study also determines if the quality of medical record keeping influences the outcome of medico-legal cases in South Africa. Lastly, it determines, by a brief comparison of relevant South African legislation and medical ethical guidance documents with relevant Canadian law, guidelines and practices, if the different medical ethical guidance documents in South Africa regarding medical record keeping have value to the required extent. The study concludes that the courts in South Africa do not always consider the medical ethical commitment that doctors have in terms of the Health Professions Act i.e. to abide by the HPCSA's medical ethical guidance booklets. Therefore the quality of medical record keeping did not influence the outcome of the cases reviewed in this study. It is also concluded that the HPCSA needs to implement a system to ensure that doctors are trained on the topics covered in the HPCSA guidance booklets, and that such training is adequately monitored. The HPCSA further ought to provide supervision in the form of physical assessments of doctors' medical record keeping practices and patient practices. This will ensure that the HPCSA regulates professional and ethical conduct, as required by the Health Professions Act. The training and assessments by the HPCSA should form part of the licensing standards to be met by doctors to practise medicine in South Africa. This will limit, to a great extent, medical errors due to inadequate record keeping in order to enhance patient safety and quality medical care. It is further concluded that the references to and repetition of relevant legislation and the HPCSA guidelines should be removed from the MPS guidelines. The HPCSA guidance Booklet 9 should be updated with the guidelines pertaining to medical record keeping in South Africa currently contained only in the MPS guidelines. This will create a consolidated guideline under the HPCSA and the current MPS guidelines can then be discontinued.