A medical record is any record made by a medical practitioner from time to time regarding consultations, examinations or recommendations pertaining to surgical procedures or any other proposed treatment.
Medical records consist of notes taken by a treating doctor as well as any previous attending doctors and health care workers which includes any summaries in this regard.
Any clinical research, x-rays, laboratory reports are included in the definition of “patient records”.
All records should be retained for at least 6 years and with matters related to minor children until such minor has reached the age of 21 plus an additional 3 years thereafter.
A medical practitioner is entitled to charge a patient a fee for these clinical records which should be made available upon request by the patient.
Alteration of Records
No information may be removed from medical records. Any changes must be made in black ink and any entries made at a later stage should be dated and signed.