Administrative tasks, such as medical aid forms and report writing, are a feature of all clinical specialties and failure to do it properly can land you in trouble with the HPCSA. Letmore Chigudu, Case Manager at Medical Protection, provides guidance on meeting expectations

Administration has always been a part of taking care of patients and no medical specialty is immune from the administrative tasks associated with patient care: insurance, Road Accident Fund (RAF) matters, injury on duty (IOD) and medical aid forms, to mention but a few. Although the burden varies across specialties, administrative duties take up a substantial portion of a practitioner’s time.

A practitioner’s administrative duty towards patients

Once a doctor-patient relationship has been established, the practitioner assumes both clinical and administrative responsibility towards the patient. Apart from the everyday administration of filling in request forms for lab tests and radiology and writing out scripts, on occasion a practitioner may be requested by patients or third parties, such as patients’ insurers, to complete forms for insurance, RAF and medical aid claims.

These are not limited to the standard proforma documents which companies often provide – sometimes a practitioner is required to draft letters of motivation or clinical reports, which take even more time to prepare. When a patient presents such a form to a practice to be filled in, it is expected of the practitioner to complete the information as requested – that is the practitioner’s professional and ethical duty.

The HPCSA’s guidelines on the keeping of patient records (booklet 9) state that a practitioner shall (in other words, must) issue a brief factual report to a patient where the patient requires information about themself. The same rule is contained in the HPCSA’s ethical and professional rules booklet. The HPCSA rules and guidance make it clear that practitioners have a duty to provide patients with reports or complete forms regarding their health, where such is requested. It is therefore likely that, if a practitioner were to fail or refuse to provide such a report or to complete a form and a subsequent complaint to this effect was made to the HPCSA, the practitioner would be called upon to justify their refusal. Although exceptional cases may exist, it is very unlikely that a refusal would be justifiable, especially where it is the patient who makes the request personally.

The Promotion of Access to Information Act states that every person has a right to access information about themselves from the person holding this information. This information includes medical records, reports or forms that have been filled in containing the requester’s personal information.

What is expected of you as a practitioner in filling out forms or writing reports?

A practitioner is expected to:

• Be factual, honest, accurate and objective
• Complete only what you have knowledge of in an unbiased manner
• Mention if the information on the form or report is as a result of personal observations during an examination or as a result of information that has been received from either the patient or another practitioner.

Booklet 5 of the HPCSA (confidentiality guidelines on protecting and providing information) further mentions that you as a practitioner:

• Should be satisfied that the patient has been told at the earliest opportunity about the extent of the information to be disclosed
• Inform the patient that relevant information cannot be concealed or withheld
• Show the form to the patient before you complete it to ensure that the patient understands the scope of the information requested
• Obtain, or have seen, written consent to the disclosure from the patient
• Disclose only information relevant to the request for disclosure
• Check whether patients wish to see their reports – unless patients have clearly and specifically stated that they do not wish to do so.

It is important to note that most reports or forms filled in are requested to assist in making certain decisions relating to the patient, for example, insurance claims, injury on duty claims, fitness to work etc. In such instances, a practitioner needs to note that the final decision rests with the people to whom the report or form is to be submitted, and not with the practitioner. The form or report that you fill in would, however, form part of the information that will be used to come to a decision regarding the patient. The general rule is that you cannot opine on the outcome of the decision.

For example, if the form is to be used to assess a patient’s ability to work or study, then it is advisable that a practitioner does not opine on the patient’s ability to perform specific specialised tasks that an employer may require the patient to do during the course of their employment. Instead, it would be advisable to only comment on the patient’s clinical condition, namely signs and symptoms, treatment and response to treatment, and thereafter make a recommendation.

There are instances where a patient might not give consent for certain information to be included on the form or report. In such a case, the wishes of the patient should be respected to maintain confidentiality. However, the patient needs to be warned of the possible negative consequences this may have. For example, failure to disclose a condition may result in the medical aid scheme declining to provide benefits to the patient.

As a practitioner it would usually be reasonable to charge a fee for the form or report if it is justifiable and defensible. However, you would need to ensure that you have obtained the patient’s informed financial consent before doing so.

However unappealing it may be to some, paperwork and administrative tasks are an inescapable and extremely important part of practice. This is confirmed in the HPCSA’s ethical rules and guidelines, as well as various laws governing healthcare in South Africa. Sound administration is good practice and can help avoid unnecessary complaints to the HPCSA.

References

• HPCSA, Confidentiality: Protecting and Providing Information (2016)
• HPCSA, Ethical and professional rules of the Health Professions of South Africa (2016)
• HPCSA, Guidelines on keeping of patient records (2016)
• Promotion of access to Information Act, 2000 PAIA