Quick answer
Request the admission notes, clinical notes, nursing notes, consent forms, operation notes, medication charts, test results, scan reports, referral letters, discharge summary, billing records and follow-up records. The exact list depends on what happened, but a discharge note alone is rarely enough.
Key takeaways
- Request the admission notes, clinical notes, nursing notes, consent forms, operation notes, medication charts, test results, scan reports, referral letters, discharge summary, billing records and follow-up records. The exact list depends on what happened, but a discharge note alone is rarely enough.
- Write a records request that identifies the patient, hospital, treatment dates and departments involved. Ask for the records in writing and keep proof of the request. Do not mark or alter original documents. Keep a separate timeline and questions list.
- There may be copying or administrative steps to obtain records. A lawyer can help decide whether to request records first, send a formal letter, brief an expert, or lodge a complaint.
- This medical negligence article is general information and still needs legal review for specific facts.
Documents and facts to prepare
- Admission record.
- Clinical and nursing notes.
- Consent forms.
- Operation or procedure notes.
- Medication charts.
- Laboratory and scan results.
- Referral letters.
- Discharge summary.
- Follow-up notes.
- Account and billing records.
Common mistakes
- Requesting only the discharge summary.
- Not asking for medication charts.
- Forgetting consent forms and operation notes.
- Losing proof of the records request.
- Posting accusations before the facts are checked.
- Waiting too long where harm or prescription risk may be serious.
Why this situation happens
Patients and families often remember the result but not the medical sequence. A serious mistake may involve a diagnosis, procedure, medication, monitoring, infection control, discharge or follow-up. Records help reconstruct the timeline.
Legal explanation
The HPCSA publishes guidance on the keeping of patient records and provides a complaint and investigation route for complaints against registered practitioners. Medical negligence assessment often needs records before an expert can say whether the care fell below an acceptable standard and whether that caused harm.
What to do next
Write a records request that identifies the patient, hospital, treatment dates and departments involved. Ask for the records in writing and keep proof of the request. Do not mark or alter original documents. Keep a separate timeline and questions list.
Costs and timeframes
There may be copying or administrative steps to obtain records. A lawyer can help decide whether to request records first, send a formal letter, brief an expert, or lodge a complaint.
FAQs
Should I request the full hospital file?
Ask what records exist and request the records relevant to the admission, treatment, procedure, medication, tests and discharge.
Can I rely only on the discharge summary?
Usually no. A discharge summary is useful, but it may not show the full timeline, nursing notes, medication chart or consent documents.
Should I request records before making an HPCSA complaint?
Often yes. Records help clarify what happened and whether the issue is a professional complaint, civil claim, or both.
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Source notes
Legal note
This article is general legal information for South African readers. It is not legal advice. Speak to a qualified legal professional about your specific facts before taking action.