C-26, r. 254 - Regulation respecting the keeping of records by medical technologists

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2.02. A medical technologist must enter the following items and information in each record:
(a)  the date of opening of the record;
(b)  the name and given names of the client at birth, the address, telephone number, health insurance number, date of birth, sex and, in the case of a married person, the name of the spouse of the client;
(c)  the name and address of the health professional who referred the said client to him, where applicable;
(d)  the requests or prescription made by a health professional or the reports provided;
(e)  a brief description of the reasons for the consultation;
(f)  a description of the professional services rendered and their date;
(g)  the nature of the specimens sampled, where applicable;
(h)  the analysis and examination methods used;
(i)  the results obtained;
(j)  the recommendations made to the client; and
(k)  the notes, correspondence and other documents pertaining to the professional services rendered.
R.R.Q., 1981, c. C-26, r. 175, s. 2.02.