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

Article 53 Versions de la disposition

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).