S-4.2, r. 23 - Regulation respecting the information that institutions must provide to the Minister of Health and Social Services

Full text
SCHEDULE IV
1. An institution referred to in section 5 of the Regulation must provide the following information:
(1) concerning the user:
(a) whether the user is a newborn;
(b) the code of the municipality where the user’s residence is located;
(c) the place of birth;
(d) the code corresponding to the user’s occupation;
(e) the user’s civil status;
(f) if the user died, the immediate cause of death according to ICD-10-CA, the type of death and whether there was an autopsy or an investigation by a coroner;
(2) concerning the accident that led to the user’s hospitalization, if applicable:
(a) the date of the accident;
(b) the code corresponding to the external cause of the accident according to ICD-10-CA;
(c) the code corresponding to the place of the accident according to ICD-10-CA;
(3) concerning the origin, admission and destination of the user:
(a) the code of the facility of origin;
(b) the type of origin;
(c) the date and time of admission;
(d) the type of admission;
(e) the diagnosis at admission according to ICD-10-CA;
(f) the type of care provided;
(g) if the user is transferred directly from the emergency department of the institution to a short-term care unit or day surgery in the same institution, the date of registration for the emergency department;
(h) the person responsible for paying the hospital stay;
(i) the date and time of leaving the facility where the care was provided;
(j) the number of days of temporary leave;
(k) the number of hospitalization days;
(l) the code of the facility that is the destination;
(m) the type of destination;
(4) the diagnosis according to ICD-10-CA;
(5) concerning any stay of the user in a service where care was provided, and any diagnosis made there:
(a) the code of the service;
(b) the type of stay;
(c) the residency status and specialty of the attending physician;
(d) the diagnosis of the affection justifying the user to stay in the service according to ICD-10-CA and the characteristic of the diagnosis;
(e) the duration of the stay in the service;
(f) the dates of the beginning and end of each type of stay;
(6) concerning any affection other than those referred to in paragraph 2 or 5 diagnosed or treated during the user’s hospitalization:
(a) the main diagnosis according to ICD-10-CA;
(b) the service in which the affection was diagnosed or treated and the characteristic of the diagnosis;
(7) concerning any medical consultation by the user during hospitalization:
(a) the service from which the request for consultation originates;
(b) the field of the consultation;
(c) the specialty of the medical consultant;
(8) the total number of consultations by the user;
(9) concerning any intervention on the user during hospitalization:
(a) the service for which the user is enrolled;
(b) the date, time and place of the intervention;
(c) the intervention code according to the Canadian Classification of Health Interventions (CCI);
(d) the status attribute of the intervention according to the CCI;
(e) the location attribute of the intervention according to the CCI;
(f) the extent attribute of the intervention according to the CCI;
(g) the number of times an intervention was performed;
(h) the residency status and specialty of the physician who performed an intervention or administered ananesthesia;
(i) the anaesthesia technique used, where applicable;
(j) the date and time the user left the operating room, where applicable;
(10) concerning any stay of the user in an intensive care unit:
(a) the code of the intensive care unit;
(b) the duration of the stay;
(11) concerning a user who received services following a birth or stillbirth:
(a) the number of stillbirths following the pregnancy concerned, if applicable;
(b) the number of stillbirths that led to an autopsy following the pregnancy concerned, if applicable;
(c) the weight in grams of a product of conception of more than 100 grams in the case of a live birth or of more than 500 grams in the case of a stillbirth;
(d) the duration of the pregnancy;
(12) concerning any transmission of information to the Minister:
(a) the financial period concerned;
(b) the type of transaction;
(c) the date of transmission;
(d) the admission number;
(e) the number of the facility on the institution’s permit where care was provided.
An institution referred to in section 5 of the Regulation must also provide the information in subparagraph c of subparagraph 11 of the first paragraph for any user born in a facility of the institution or who was admitted there within 28 days of birth.
The institution must also provide the information in subparagraph d of subparagraph 11 of the first paragraph for any user born in a facility of the institution, including the number of the mother’s medical record.
2. In addition to the information required under section 1, an institution referred to in section 5 of the Regulation that makes a tumour diagnosis must provide the following information:
(1) concerning the user: the name of the mother at birth and the name of the father;
(2) concerning any diagnosed tumour of the user: its topography according to ICD-10-CA, its morphology according to the International Classification of Diseases: oncology, 1st Edition (ICD-O-3) and how the tumour was diagnosed.
O.C. 103-2009, Sch. IV; O.C. 859-2018, s. 3.
SCHEDULE IV
1. An institution referred to in section 5 of the Regulation must provide the following information:
(1) concerning the user:
(a) whether the user is a newborn;
(b) the code of the municipality where the user’s residence is located;
(c) the place of birth;
(d) the code corresponding to the user’s occupation;
(e) the user’s civil status;
(f) if the user died, the immediate cause of death according to ICD-10-CA, the type of death and whether there was an autopsy or an investigation by a coroner;
(2) concerning the accident that led to the user’s hospitalization, if applicable:
(a) the date of the accident;
(b) the code corresponding to the external cause of the accident according to ICD-10-CA;
(c) the code corresponding to the place of the accident according to ICD-10-CA;
(3) concerning the origin, admission and destination of the user:
(a) the code of the facility of origin;
(b) the type of origin;
(c) the date and time of admission;
(d) the type of admission;
(e) the diagnosis at admission according to ICD-10-CA;
(f) the type of care provided;
(g) if the user is transferred directly from the emergency department of the institution to a short-term care unit or day surgery in the same institution, the date of registration for the emergency department;
(h) the person responsible for paying the hospital stay;
(i) the date and time of leaving the facility where the care was provided;
(j) the number of days of temporary leave;
(k) the number of hospitalization days;
(l) the code of the facility that is the destination;
(m) the type of destination;
(4) the diagnosis according to ICD-10-CA;
(5) concerning any stay of the user in a service where care was provided, and any diagnosis made there:
(a) the code of the service;
(b) the type of stay;
(c) the residency status and specialty of the attending physician;
(d) the diagnosis of the affection justifying the user to stay in the service according to ICD-10-CA and the characteristic of the diagnosis;
(e) the duration of the stay in the service;
(6) concerning any affection other than those referred to in paragraph 2 or 5 diagnosed or treated during the user’s hospitalization:
(a) the main diagnosis according to ICD-10-CA;
(b) the service in which the affection was diagnosed or treated and the characteristic of the diagnosis;
(7) concerning any medical consultation by the user during hospitalization:
(a) the service from which the request for consultation originates;
(b) the field of the consultation;
(c) the specialty of the medical consultant;
(8) the total number of consultations by the user;
(9) concerning any intervention on the user during hospitalization:
(a) the service for which the user is enrolled;
(b) the date and place of the intervention;
(c) the intervention code according to the Canadian Classification of Health Interventions (CCI);
(d) the status attribute of the intervention according to the CCI;
(e) the location attribute of the intervention according to the CCI;
(f) the extent attribute of the intervention according to the CCI;
(g) the number of times an intervention was performed;
(h) the residency status and specialty of the physician who performed an intervention or administered ananesthesia;
(i) the anaesthesia technique used;
(10) concerning any stay of the user in an intensive care unit:
(a) the code of the intensive care unit;
(b) the duration of the stay;
(11) concerning a user who received services following a birth or stillbirth:
(a) the number of stillbirths following the pregnancy concerned, if applicable;
(b) the number of stillbirths that led to an autopsy following the pregnancy concerned, if applicable;
(c) the weight in grams of a product of conception of more than 100 grams in the case of a live birth or of more than 500 grams in the case of a stillbirth;
(d) the duration of the pregnancy;
(12) concerning any transmission of information to the Minister:
(a) the financial period concerned;
(b) the type of transaction;
(c) the date of transmission;
(d) the admission number;
(e) the number of the facility on the institution’s permit where care was provided.
An institution referred to in section 5 of the Regulation must also provide the information in subparagraph c of subparagraph 11 of the first paragraph for any user born in a facility of the institution or who was admitted there within 28 days of birth.
The institution must also provide the information in subparagraph d of subparagraph 11 of the first paragraph for any user born in a facility of the institution, including the number of the mother’s medical record.
2. In addition to the information required under section 1, an institution referred to in section 5 of the Regulation that makes a tumour diagnosis must provide the following information:
(1) concerning the user: the name of the mother at birth and the name of the father;
(2) concerning any diagnosed tumour of the user: its topography according to ICD-10-CA, its morphology according to the International Classification of Diseases: oncology, 1st Edition (ICD-O-3) and how the tumour was diagnosed.
O.C. 103-2009, Sch. IV.