What must a patient record contain under HPCSA Booklet 9, and how long do you keep it?

Booklet 9 asks for a record that is contemporaneous, accurate, attributable, accessible and secure, holding the patient's identity, history, allergies, the time and place of each consultation, the assessment, plan, medication, referrals, results and written consent where relevant. Keep it at least six years from dormancy, until 21 for a minor and for life for a mentally incapacitated patient.

What the record must hold

Booklet 9 lists the compulsory elements, from the patient's identifying particulars and full history with allergies to the time, date and place of consultation, the assessment, the management, the medication, referrals, response to treatment, investigations and written proof of informed consent.¹ Each entry must be identifiable to the person who made it, and late entries must be noted as such with a reason.¹ The HPCSA files the September 2022 revision on its Ethics page as a review draft, and it is the version it lists.¹

How the OHSC audits it

1. Record identity in full. Name, a unique registration number, sex, an ID number or date of birth or passport or refugee number, address, contact details and next of kin.
2. Record each consultation. Date, time, allergies, assessment, plan, medication, referrals, adverse effects, results and agreed follow-up.
3. Sign every entry. The OHSC tool scores a signature on each entry, and Rule 15 asks for initials and surname printed beside it on official documents.
4. Show results were acted on. Results in the record, reviewed by the doctor, and the patient told.
5. Set retention and disposal. Six years from dormancy at least, with a register of archived and disposed records and copies of disposal certificates.

1. Record ______ Seen on ______ Audited by ______
2. Identity, unique number, ID or date of birth, address, next of kin ______
3. Date and time ______ Allergies ______ Assessment ______ Plan ______
4. Medication ______ Referrals ______ Results reviewed and told ______
5. Every entry signed ______ Consent recorded where needed ______
6. Retention date ______

Copy template

Retention and security

Booklet 9 says records should ideally be kept indefinitely, electronically, and otherwise for at least six years from dormancy, with longer periods for minors, incapacitated patients and occupational health records.¹ Regulation 6 requires a filing, archiving, disposal, storage and retrieval system that complies with the law, and confidentiality under sections 14, 15 and 17 of the National Health Act.³ Section 17 makes the person in charge set up controls against unauthorised access to records and to the system that keeps them.⁴ The OHSC tool scores the records procedure on retention, access, release to third parties, archiving and disposal.⁶

Questions

Is Booklet 9 in force if the HPCSA calls it a review draft?

It is the version the HPCSA lists on its Ethics page, and the OHSC's general practice tool scores records against its sections 4.1, 4.2 and 9, so practices are inspected against it.

Are electronic records acceptable?

Yes. The OHSC tool accepts manual or electronic records, and asks that electronic records be protected with passwords or other security measures.

Who owns the patient record?

The practitioner or entity that generated it, under Booklet 9, while the patient is entitled to access the information in it.

Sources

1. 1Health Professions Council of South Africa, 2022Booklet 9, Guidelines on the keeping of patient health records, revised September 2022 (published as a review draft)Read source
2. 2Office of Health Standards Compliance, 2025Regulatory General Practice Inspection Tool v1.1, Clinical Care and SupportRead source
3. 3Office of Health Standards Compliance, 2018Norms and Standards Regulations applicable to different categories of health establishments, GNR 67, Government Gazette 41419, 2 February 2018Read source
4. 4South African Government, 2004National Health Act 61 of 2003, Government Gazette 26595, 23 July 2004Read source
5. 5Health Professions Council of South Africa, 2023Ethical Rules of Conduct for Practitioners registered under the Health Professions Act, GNR 717 of 2006, as amended to BN 510 of 2023Read source
6. 6Office of Health Standards Compliance, 2025Regulatory General Practice Inspection Tool v1.1, Administration and Practice ManagementRead source

Written by the wai team from Health Professions Council of South Africa and Office of Health Standards Compliance guidance, checked on 16 October 2026. This is guidance, not legal advice. Neither the OHSC nor the HPCSA endorses wai or any software.