Access to Confidential Medical Records

Confidentiality and record keeping:

The Medical Records of patients are the property of the doctor and not the patient. The National Health Act 2003 obliges healthcare providers to create and maintain a medical record for each of their patients. Moreover, it requires us to introduce control measures to safeguard and restrict access to those records or the records’ storage facility by authorised personnel. Records are not retained randomly on an indefinite basis and the HPCSA advises records to be kept for at least 6 years after they become dormant. There are expectations to this rule for children and the mentally impaired.

 All patients have the right to confidentiality. Relatives have no automatic right of access to an adult patient’s records.

Relatives may apply for access on behalf of the patient in the presence of an empowering law, informed consent or a court order

Once tasked with this request, records are carefully studied to ensure the disclosure to the “the relevant person” (patient or other persons requesting access) does not potentially cause “harm to the patient’s physical or mental health, or well-being” nor is a breach of confidentiality.

The Process:

 Many people do not understand the time-consuming and legal bureaucracy involved in the formal  process of the provision of access to medical records.

It is not a matter of a receptionist simply photocopying a doctor’s notes and handing them over. There are clearly defined rules and laws that must be followed meticulously to avoid a breach of confidentiality. The entire procedure is documented, standardized and often involves multiple layers of approval 

Step 1.  

Send your Medical Report request in writing; or a provide a signed consent form to your nominated medical. in the cases of incapacitated patients, a court order is required. Your recent Advanced Directive will be considered.

If you become critically ill, and unable to communicate your wishes, I will consult with your Medical Proxy concerning the terms of your directive. This gives you another layer of protection in ensuring your wishes are respected.

 South African common law determines that a power of attorney terminates once the principal becomes incapacitated. In other words, when a principal is no longer able to perform the act in question himself, the agent can no longer do it for him. A validly concluded power of attorney therefore automatically lapses as soon as the principal loses the legal capacity to act.

 Advance directives – although ethically acceptable – are currently not recognised as legally enforceable instructions in terms of South African law. A patient’s contemporaneous decision to refuse medical treatment and/or food and drink is valid in South African law. An advance directive, by definition, does not amount to a contemporaneous refusal of medical treatment – but rather, a prospective decision to refuse medical treatment.  

 This means that you can change your mind at any time. Any instructions you give orally will over-ride previously written instructions provided you are competent when you express them.

 If your doctor (or any other concerned person) believes that your proxy is failing to comply with your stated wishes, and that their actions are likely to cause harm to your physical or mental health, we may lodge a complaint with the Office of the Minister of Health who will investigate the complaint and who may then appoint another Medical Proxy.

 Your trusted Medical Proxy for personal care and medical decisions may be a different person to whom you’ve granted authority to act in financial and legal matters by giving him Power of Attorney for Property. 

For more information see Dignity SA’s advice on planning an Advanced Directive and template form.

 

Step 3.

Once we have received your request in writing and the correct paper work as described above including acceptance of the quotation for this medical drafting service, we will begin the process.  

Step 4.

We first attempt to retrieve your physical records from storage. Dr Pieper is retired and lives in Stellenbosch so this step can take time. Other records may be extracted from a secure online database once consent has been signed and granted. We may need to request additional records from previous specialists and other clinicians, once we have requested these old records, there may be an additional turnaround time from those doctors. We may also put in requests from laboratories or radiology departments to extract old data. Once all your records are collected,  

My assistant will arrange a time in my diary to get started on your report. We book this medical service out during office hours. We understand the importance and urgency of this report to you but also triage medical emergencies and take into consideration the importance and urgency of other patients who may be sick and have booked our time prior to your request for paper work. Drafting and administrative appointments are often booked towards the end of the day as they often extend into our after hours and can literally take hours, if not days, of our time.

Schedule of professional fees:

 Doctors’ in South Africa are free to levy fees according to what they regard as appropriate for services rendered based on their overheads. Fees for medical services rendered are to be paid immediately. Please discuss treatment costs BEFORE services and professional fees are rendered and find attached your quotation. Fees are based on length of time, complexity and extent of advice. 

Estimate:
R750.00 for Mole Mapping records*, excluding hard drive.
R750.00 for other medical records, excluding photocopying/ scanning/printing (R3.00 per page).

Please be advised that most funders no longer pay clinicians or hospitals directly even if we had to attempt to submit your account to your insurance on your behalf. Most now reimburse the patients’ personal bank account directly without notification. As you can imagine this creates a very tenuous and awkward situation for clinicians, debt collecting interferes with the patient/doctor relationship so have to outsource this service to third parties to track and collect fees before patients inadvertently spend the insurance payout.

I hold no contract with any insurance scheme. Medical schemes and their administrators do have justifiable grounds to inform patients that a doctor’s costs are excessive according to their BENEFIT structure as there is no industry standard for doctor’s professional fees, all funders have different “medical aid rates” and funders provide BENEFITS to patients according to the package options selected by patients whilst doctor’s charge professional fees for services rendered to patients.

Professional fees charged by doctors and BENEFITS may differ. Schemes determine the level of benefit they are prepared to pay for services rendered.

 My accountant will furnish you with an invoice within 10 working days that you may submit to your funder so they can reimburse you based on the benefits they have provided for you.

 Mole Mapping:

If Mole Mapping* images are requested, they are placed on a brand new flash drive which we will provide. We will not risk our servers being inoculated with malware. Mole Mapping images are large files of the entire body and due to size and their sensitive nature cannot be sent over the internet.

Collection:

When your records are ready you will received an email to come in. Please come in person to collect your confidential records with your ID book. You can send a trusted friend to collect them if they have a letter signed with your informed consent and a signed copy of your ID. You will also receive a call to confirm before hand over. Please note your file may contain sensitive information and images,

I will not give out your confidential medical records without this for your safety and privacy. I trust this is in order.