S-5, r. 5 - Organization and Management of Institutions Regulation

Section 53 Disposition versions

2012-09-01

53. The record kept by a hospital centre shall include:

(1)  report of outpatient services;

(2)  medical observation, physical examination, provisional diagnosis and dental examination;

(3)  prescriptions;

(3.1)  a record of the preparation and administering stages of medication;

(4)  progress notes by physicians, dentists, pharmacists and members of the clinical staff;

(5)  report on the need for close treatment and on the capacity of the person to manage his property made under the Mental Beneficiaries Protection Act (chapter P-41)* and reviews thereof;

(6)  requests for and reports on consultation;

(7)  requests for and reports on treatment;

(8)  summary of interviews with professionals;

(9)  items used in arriving at a diagnosis or in prescribing a treatment, such as photographs, ultrasonic pictures, X-rays as well as parts of electrocardiograms and electroencephalograms and other relevant documents;

(10)  reports of diagnostic examinations;

(11)  the document required by section 52.1;

(12)  the document attesting that the beneficiary’s consent was obtained for the care or services provided by the hospital centre;

(13)  anaesthetic procedure;

(14)  pre-operation diagnosis, nature of proposed surgery, operating procedure indicating the nature of the surgery, findings, operating techniques used and description of the parts removed;

(15)  anatomical-pathological report and cytological report;

(16)  reports of nosocomial infection;

(17)  requests for transfer;

(18)  reports on accidents to beneficiaries in any institution;

(19)  the summary sheet, comprising the principal diagnosis, the order diagnoses and problems, complications, medical, surgical or obstetrical treatment, special examinations and the attestation of the attending physician confirming authenticity;

(20)  a note of the beneficiary’s leaving;

(21)  notice of discharge by the attending physician or dentist and a note that the beneficiary has left;

(22)  beneficiary’s consent for the institution to take photographs, films or recordings of him;

(23)  copy of the death certificate;

(24)  report of autopsy.

O.C. 1320-84, s. 53; O.C. 545-86, s. 20; O.C. 375-88, ss. 1 and 13.

*Act replaced by the Act respecting the protection of persons whose mental state presents a danger to themselves or to others (chapter P-38.001).