[Clinic name]
Controlled document
[Address]
[Registration or licence number]
HPCSA and OHSC inspection checklist
1Procedures and registers
- Standard operating procedures for complaints, triage, records, consent and adverse events, signed, dated and reviewed within 5 years.
- A complaints register with entries from the past twelve months, or zero reporting documented.
- An adverse events register, with reporting to the structure that monitors it.
- Training and orientation records with an attendance register.
2The patient record
- Three recent records an inspector could audit cold, each entry dated, timed and signed.
- Name, unique number, ID or date of birth, address, contacts and next of kin recorded.
- Results in the record, reviewed by the doctor and told to the patient.
- Retention set to at least six years from dormancy, longer for minors.
3Consent and confidentiality
- A formal informed consent procedure, including emergencies and legal standing.
- Written consent for complex or high risk procedures, and the discussion in the record.
- Records secured, electronic records behind passwords or other controls.
- An Information Officer registered with the Information Regulator.
4People and premises
- Every practitioner's HPCSA registration checked for the current year.
- Basic life support training current for health care providers.
- The emergency trolley stocked, checked and in date, oxygen ready.
- An occupational health and safety risk assessment, with mitigation plans.
5What an HPCSA and OHSC inspector may ask
- May I see three records of patients seen this month? What to show, complete records with identity, date, time, assessment, plan, results and a signature on every entry.
- Show me your complaints register and how complainants were answered. What to show, entries from the past twelve months and three resolved complaints with the reply sent.
- How do you obtain and record informed consent? What to show, the consent procedure and records where the discussion and the patient's agreement are written down.
- How do you monitor and report adverse events? What to show, the adverse events register, the reporting route and what changed after each event.
- Who can open a patient record, and how is that controlled? What to show, roles, access controls, an access log and where records are hosted.
- Where do you use AI, and who checks it? What to show, where it is used, how patients are told, and who signs each output, as Booklet 20 asks.
AAppendix, OHSC inspection readiness log
- A.1Practice ______ Inspection date ______ Notice received ______
- A.2Person in charge ______ Deputy ______
- A.3Procedures signed and within review date ______
- A.4Complaints register, last 12 months ______ Adverse events register ______
- A.5Three records audited ______ Gaps found ______
- A.6Emergency trolley checked by ______ On ______
- A.7Gap ______ Owner ______ Due ______