The evolution of medicolegal record-keeping laws in South Africa is deeply intertwined with the country's broader healthcare reforms and legal frameworks. This development has been shaped by constitutional rights, legislative acts, and professional guidelines.
Constitutional Framework
The South African Constitution (1996) forms the foundation for health record management by enshrining the right to access healthcare services under Section 27(1)(a) and the right to privacy under Section 14. These provisions underscore the importance of maintaining accurate and confidential health records (Kolawole, 2024).
Legislative Developments
National Archives Act (1996): This Act regulates how records are kept, including health records.
Promotion of Access to Information Act (2000): For instances, such as court cases this Act ensures that individuals have access to their personal information, including medical records. Note that this access requires the correct procedures to be followed to obtain a copy of the medical records.
Protection of Personal Information Act (POPIA) (2013): Mandates how personal information must be handled securely and confidentially.
National Health Act No. 61 of 2003: Requires every public health facility to maintain comprehensive patient records under Section 13.
Policy Initiatives
White Paper on Transformation of Health System (1997): Emphasised health facility record management as crucial for an effective national healthcare system.
District Health Management Information System Policy (2011): this Act called for standardisation of data collection and recording for all healthcare providers.
National Health Normative Standards Framework for Interoperability in eHealth (2014): Promotes secure electronic exchange and storage of clinical data.
Standard Operating Procedure for Filing, Archiving, and Disposal of Patient Records: Published in 2016 to guide healthcare providers on proper procedures for storage and disposal of medical records.
Professional Guidelines
The Health Professions Council of South Africa (HPCSA) mandates guidelines on patient record keeping. The revised guidelines from 2022 emphasise best practices for collecting and managing health records. These guidelines are crucial for continuation of medical care and essential during litigation or court orders (Marutha, 2020). Despite these developments, challenges persist within healthcare facilities regarding non-compliant medical record keeping.
In summary, South Africa's medicolegal record keeping has evolved through a combination of constitutional rights protection, legislative requirements, policy initiatives aimed at standardisation, along with professional guidance from bodies like HPCSA. However, there remains a need for improved compliance within healthcare facilities to ensure reliable patient care documentation that supports both legal proceedings and quality healthcare delivery.
The creation, enrichment, and editing of this article for enhanced clarity was facilitated by the use of Perplexity Ai rewrite https://www.perplexity.ai (accessed 17th February 2025.)
References:
KOLAWOLE, O. 2024. Non-compliant health record-keeping in South Africa: Judicial responses, and progress towards a digital remedy. The African Journal of Information and Communication (AJIC), 1-19.
MARUTHA, N. 2020. Medical records preservation strategies in improving healthcare service providers’ access to patients’ medical histories in the Limpopo hospitals,
https://www.hpcsa-blogs.co.za/guidelines-on-patient recordkeeping/?utm_source=HPCSA+eBulletin&utm_campaign=4f547feec7-EMAIL_CAMPAIGN_2022_11_17_06_29&utm_medium=email&utm_term=0_f2379b87e7-4f547feec7-57757301&mc_cid=4f547feec7&mc_eid=9b8cc14bcb
Accessed 19/11/2022
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