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

Section 56 Disposition versions

2012-09-01

56. The record kept by a local community service centre shall include:

(1)  a file index;

(1.1)  a summary sheet;

(2)  a medical or psychosocial assessment or an assessment of the beneficiary’s autonomy;

(3)  reports of diagnostic examinations;

(4)  request for services;

(5)  prescriptions;

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

(6)  treatment plan and periodic review reports;

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

(8)  consultation requests and reports;

(9)  the document required by section 52.1;

(10)  the document attesting that the beneficiary’s consent was obtained for the care or services provided by the local community service centre;

(11)  reports of accidents to beneficiary in an institution;

(12)  beneficiary’s consent to the institution’s taking of photographs, films or recordings of him;

(13)  photographs, X-rays, electrocardiograms and electroencephalograms, and other evidence used in arriving at a diagnosis or in prescribing a treatment;

(14)  anaesthetic procedures;

(15)  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;

(16)  a copy of the death certificate.

O.C. 1320-84, s. 56; O.C. 545-86, s. 22; O.C. 375-88, ss. 1 and 4.