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

Updated to 1 September 2012

This document has official status.

chapter C-26, r. 254

Regulation respecting the keeping of records by medical technologists

Professional Code

(chapter C-26, s. 91).

DIVISION I GENERAL PROVISIONS

1.01. In this Regulation, unless the context indicates otherwise,

(a)  “Order” means the Ordre professionnel des technologistes médicaux du Québec;

(b)  “medical technologist” means whosoever is entered on the roll of the Order.

R.R.Q., 1981, c. C-26, r. 175, s. 1.01.

1.02. The Interpretation Act (chapter I-16) applies to this Regulation.

R.R.Q., 1981, c. C-26, r. 175, s. 1.02.

1.03. Nothing in this Regulation shall be interpreted as excluding the use of data processing or any other technical means in the drawing up and keeping of the records of a medical technologist.

R.R.Q., 1981, c. C-26, r. 175, s. 1.03.

DIVISION II KEEPING OF RECORDS

2.01. Subject to section 2.07, a medical technologist must keep a record for each of his clients at the place where he practises his profession.

R.R.Q., 1981, c. C-26, r. 175, s. 2.01.

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.

2.03. A medical technologist must keep each record up-to-date until he ceases to render professional services to the person concerned by that record.

R.R.Q., 1981, c. C-26, r. 175, s. 2.03.

2.04. A medical technologist must keep each record for at least 5 years from the date of the last service rendered.

R.R.Q., 1981, c. C-26, r. 175, s. 2.04.

2.05. A medical technologist must keep his records in a room or cabinet which is not readily accessible to the public and which may be locked by means of a key or otherwise.

When, in accordance with section 1.03, the medical technologist uses data processing or any other technical means in the drawing up and keeping of his records, he must ensure that they remain confidential.

R.R.Q., 1981, c. C-26, r. 175, s. 2.05.

2.06. Where a client takes a document from the record concerned him, the medical technologist must insert in that record a note signed by the client stating the nature of the document and the date on which it was taken out.

R.R.Q., 1981, c. C-26, r. 175, s. 2.06.

2.07. Where a medical technologist is a member of or employed by a partnership, or if he is employed by a natural or legal person, the records kept by such partnership or employer in respect of the persons to whom services are rendered by that medical technologist are considered, for the purposes of this Regulation, to be the latter’s records if he may enter therein the items or information referred to in section 2.02; if he cannot do so, he must keep a record for each of these persons.

The medical technologist must sign or initial each entry or report that he puts in a record of his partnership or employer.

Where a medical technologist practises in a institution within the meaning of the Act respecting health services and social services (chapter S-4.2) or the Act respecting health services and social services for Cree Native persons (chapter S-5), the recipient’s record within the meaning of that Act and its regulations shall be considered, for the purposes of this Regulation, as the record of that medical technologist if he may enter or have entered therein, in report form or otherwise, the information referred to in section 2.02; in such case, the medical technologist need not comply with sections 2.04 to 2.06.

The medical technologist must sign or initial each entry that he puts in the said record.

R.R.Q., 1981, c. C-26, r. 175, s. 2.07.

REFERENCES

R.R.Q., 1981, c. C-26, r. 175