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

Section 55 Disposition versions

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).