Abstract
Keeping good quality medical records is an essential yet oftenneglected part of a health-care practitioner’s workload. In South Africa, by lawall health care facilities are required to retain medical records for a minimum ofsix years after the cessation of a patient’s treatment. In an archival survey thatwas attempted in a rural community in South Africa, only 39% of the recordsthat were requested were located. The procedure that was followed in order toobtain the records to be included in the survey is briefly described in this paper,highlighting the challenges experienced in four district hospitals in this community.The phenomenon has serious implications not only for the quality of healthcare,incidence of iatrogenic injuries and the future of the health-care practitioner’s career, but it also impacts on the ability to conductresearch to inform practice. An aspect that is not often considered is the impact of poor record keeping on the research and teachingcomponent of the broader medical profession.
Highlights
By law adequate medical records should be kept by all health professionals
In this study only 3% (n=2) of the folders that were retrieved were incomplete. This finding compares well with the prospective survey that was conducted by Raff and James (2003) where 25% of the records contained no information of anaesthetic procedures and 45% of the total sample was incomplete or illegible
In conclusion, inadequate record keeping was found to be a major obstacle to doing archival research in a rural community in South Africa
Summary
By law adequate medical records should be kept by all health professionals These records contain valuable infor mation regarding the patient’s condi tion and management at the health-care institution (Health Professionals Council of South Africa (HPCSA, 2008). Inadequate care could result in patient dissatisfaction with the healthservices delivered. The patient could potentially file a malpractice com plaint against a health-care practitioner. In such cases, medical records serve as a medico-legal document (HPCSA, 2008). According to the MPS casebook, inadequate record keeping can result in the end of a health-care prac titioner’s career if a complaint is made against the practitioner, and the medi cal records are insufficient to defend the practitioner’s case (MPS, 2012)
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