Health Records are mandatory for ALL Patients

The SA Defence department will have to pay damages for the failure of military doctors to diagnose the 13-year-old son of a firefighter with swine flu, the Western Cape High Court has ruled.

Torrian Marthinus, now 20, was left untreated for almost a week in August 2009 and developed meningitis – which led to seizures that affected his academic performance. The amount of damages to be paid has not been decided, notes a Weekend Argus report. Marthinus was sent to a military hospital since his father was a military firefighter.

‘The doctors did not have the treatment notes from our client’s previous visits to the hospital before them,’ Tzvi Brivik, Marthinus’s attorney, is quoted as saying, noting: ‘This placed them at a disadvantage when rendering appropriate… medical care. They had to rely on the patient, who was a minor, or his father, who was not medically trained, to provide a medical history.’ He added: ‘The Health Act 61 of 2003 obliges a health establishment to ensure health records containing prescribed information are created and maintained for every user of its health service.

Brivik said Health Professions Council of SA guidelines said patient records had to be kept, including handwritten notes. While tests established he had swine flu, doctors treating him failed to diagnose the meningitis until about six days later.

Full Weekend Argus report (subscription needed)