Best Practice Guidelines: Healthcare Practice Management & POPIA Compliance Framework

Best Practice Guidelines: Healthcare Practice Management

POPIA Compliance Framework




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8. Clinical Information: Roles & Purpose

Responsible Role

Operational Role:
  • The practitioner is the only person legally allowed to complete and access clinical/medical information about the patient.
  • Complete clinical Information to record the patient’s health information, treatments, and medications.
  • The practitioner must legally maintain patient health records for no less than six years, depending on the speciality.

Collection stage:

  • Information quality

Compliance continuity stage:

  • Updated information
  • Confidentiality measures


Purpose of Clinical Information

  • Capturing clinical information will assist the practitioner in diagnosing the patient and ensure that an accurate history of each patient and the patient event is kept.
  • When a patient requires further medical attention, medical records will assist the practitioner in making the correct diagnosis and applying the proper treatment.
  • Updated Clinical information can be sent to other practitioners, for example, Specialists, to assist in further treatment.
  • During legal proceedings between the patient and practitioner, clinical records can be helpful.
  • We always say it never happened if it is not written down.
  • All Clinical Forms will be saved under the patient Clinical History and can be viewed, printed or edited at any time.