Non-compliant health record-keeping in South Africa: Judicial responses, and progress towards a digital remedy

Abstract

Numerous South African public health facilities fail to meet their record-keeping obligations as required by law. One of the impacts of this non-compliant medical record-keeping is, as this study found, the undermining of medical negligence claims. The study reviewed numerous South African medical negligence court cases in which an absence of comprehensive, reliable patient records was central to the court’s judgment. The research also examined progress towards, and challenges facing, the South African government’s efforts to improve medical record-keeping through implementation of a national, digital Health Patient Registration System (HPRS) comprising online electronic medical records (EMRs) linked to unique personal identifiers. Based on the study findings, this article concludes with a call for the South African courts to take steps to compel the state, and public health facilities, to meet the record-keeping requirements contained in the country’s applicable legal- regulatory and policy instruments.

Keywords

• health care, records, medical negligence claims, court proceedings, judicial decisions, electronic medical records (EMRs), Health Patient Registration System (HPRS), South Africa