Best Practice Guidelines: Healthcare Practice Management & POPIA Compliance Framework

Best Practice Guidelines: Healthcare Practice Management

POPIA Compliance Framework

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9. Clinical Information: Roles, Purpose & Process Diagram

Responsible Role

The practitioner is the only person who is legally allowed to complete and access clinical/medical information about the patient.

Clinical Information will be completed by the medical practitioner to keep a record of the patient’s health information, treatments, and/or medications that are used or will be used. The practitioner is legally bound to keep patient health records for a period of no less than 6 years.

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 is kept of each patient and patient event.
  • When a patient requires further medical attention medical records will assist the practitioner in making the correct diagnosis and applying the right treatment.
  • During the course of legal proceedings between the patient and practitioner clinical records can be helpful.
  • We always say if it is not written down, it never happened.

myGC patient app

  • Sharing of clinical information (special personal information) goes through myGC. The patient keeps control over the sharing information and can at any time stop the sharing. 

Clinical business processes

By following the Clinical Information diagram you will sufficiently capture all of the clinical/medical information that is necessary to successfully fulfil your role as a practitioner.

The following sub chapters will provide details pertaining to each segment in the diagram.