HPCSA Guidelines on the Keeping of Patient Records

Canada · CEU points & talks · Psychologists

The HPCSA Guidelines on the Keeping of Patient Records (Booklet 9) was revised in September 2022. This guidance document provides the health care professional with the minimum legal standards on keeping client records. 

The presenter will take the delegates through the specifics such as what constitutes a client record, what information needs to be documented and kept safe, retention of records, etc. What to do in the event of selling your practice, or untimely death of the health care professional, will also be discussed.

Auditing of records by medical schemes is something that happens more regularly - this will also be touched on.

Practical advice on keeping notes in a S(ubjective), (O)bjective, (A)ppraisal, (P)lan format will also be discussed

Learning Outcomes:

By the end of this talk, participants will be able to:

• Understand the key components of the HPCSA's revised guidelines on patient records (2022).

• Learn what information is legally and ethically required in client records.

• Identify appropriate methods for safeguarding, storing, and retaining psychological records.

• Gain clarity on handling transitions such as selling a practice or unplanned practitioner incapacity.

• Improve your note-keeping with practical guidance on using the SOAP format.

• Prepare for possible audits by medical schemes with confidence and compliance.

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