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

Article 55 Versions de la disposition

2012-09-01

55. The record kept by a reception centre shall include:

1°  a file index;

1.1°  a summary sheet;

2°  a medical assessment of the beneficiary;

3°  an assessment of the beneficiary’s autonomy;

4°  reports of diagnostic examinations;

5°  request for services;

6°  prescriptions;

6.1°  a record of the preparation and administering stages of medication;

7°  the treatment plan and the periodic review reports;

8°  progress notes by physicians, dentists, pharmacists and members of the clinical staff;

9°  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;

10°  requests for and reports on consultation;

11°  the document attesting that the beneficiary’s consent was obtained for the care or services provided by the reception centre;

12°  (paragraph replaced);

13°  requests for transfer;

14°  reports on accidents to beneficiaries in any institution;

15°  report on confinement or isolation measures taken;

16°  beneficiary’s consent for the institution to take photographs, films or recordings of him;

17°  photographs, X-ray plates, electrocardiograms and electroencephalograms, and other evidence used in arriving at a diagnosis or in prescribing a treatment;

18°  notice of discharge and a note that the beneficiary has left;

19°  copy of the death certificate.

O.C. 1320-84, s. 55; O.C. 545-86, s. 21; O.C. 375-88, ss. 1, 4 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).