34. A licensee must ensure that every patient’s privacy is respected and every patient is treated with dignity and respect.
Safeguard against abuse and neglect
35. A licensee must ensure that —
(a)
every patient is protected from abuse or neglect by any personnel in the course of receiving care and treatment; and
(b)
there is in place a proper system to report any such abuse or neglect to an appropriate authority so that appropriate action may be taken against the personnel.
Communications with patients
36.—(1) A licensee must implement effective measures to ensure that every patient receives accurate, complete and timely information about the patient’s care and treatment.
[S 414/2023 wef 26/06/2023]
(2) A licensee must establish and implement an appropriate system for obtaining the consent of a patient for any medical procedure that is carried out, or to be carried out, in the provision of the licensable healthcare service, and maintaining a proper record of the consent obtained.
[S 414/2023 wef 26/06/2023]
(3) Where, in the provision of a licensable healthcare service by a licensee, a test is conducted (whether or not by the licensee) on a patient who is under the direct care of the licensee, the licensee must ensure all of the following:
(a)
the findings of the test are brought to the attention of the requestor without undue delay;
[S 414/2023 wef 26/06/2023]
(b)
the requestor reviews the findings in a timely manner;
[S 414/2023 wef 26/06/2023]
(c)
the patient is informed, without undue delay, of the findings that, in the professional opinion of the requestor, are clinically significant;
[S 414/2023 wef 26/06/2023]
(d)
the requestor advises the patient, based on the findings and without undue delay, on the patient’s condition, prognosis and clinical management.
[S 414/2023 wef 26/06/2023]
[S 414/2023 wef 26/06/2023]
(4) In this regulation, “requestor”, in relation to a test conducted on a patient, means —
(a)
the medical practitioner, dentist or collaborative prescribing practitioner who ordered the test for the patient; and
(b)
any medical practitioner, dentist or collaborative prescribing practitioner designated by the person mentioned in sub-paragraph (a) to carry out any duty mentioned in paragraph (3)(a), (b), (c) or (d).
[S 414/2023 wef 26/06/2023]
Information to be contained in patient health records
37.—(1) A licensee must keep and maintain, for such period and in such manner as the Director-General may specify, an accurate, complete and up‑to‑date patient health record of every patient in accordance with this regulation.
[S 414/2023 wef 26/06/2023]
(2) A patient health record must contain all of the following information relating to the patient:
(a)
name;
(b)
identification number or passport number;
(c)
gender;
(d)
date of birth.
(3) In addition, a patient health record must contain all of the following information in relation to the patient, if the information is available to the licensee:
(a)
residential address;
(b)
ethnic group;
(c)
date and time of every consultation, referral, admission, investigation and discharge;
(d)
admission forms and patient registration number for the visit, consultation or admission;
[S 414/2023 wef 26/06/2023]
(e)
medical history, referral documents and declaration forms relating to the patient’s health or medical history;
[S 414/2023 wef 26/06/2023]
(f)
clinical findings and progress notes;
(g)
clinical management and care plan containing details such as medication, nursing care, treatment, diet and allied health care;
(ga)
the name of each medical practitioner or dentist (as the case may be) who has provided care or treatment to the patient;
[S 414/2023 wef 26/06/2023]
(gb)
the date of and reason for each medical certificate issued to the patient;
[S 414/2023 wef 26/06/2023]
(gc)
any consent or acknowledgment forms;
[S 414/2023 wef 26/06/2023]
(h)
allergies and other factors requiring special consideration;
(i)
results of laboratory tests;
(j)
reports of X-rays and other investigations;
(k)
vaccinations;
(l)
consent forms;
(m)
discharge summary containing details such as significant findings and events of the patient’s stay, the patient’s condition on discharge and recommendations and arrangements for future care;
(ma)
health declaration forms;
[S 414/2023 wef 26/06/2023]
(mb)
financial counselling forms;
[S 414/2023 wef 26/06/2023]
(mc)
records of any adverse event that occurred in the provision of the licensable healthcare service and the actions taken by the licensee’s personnel in response to the adverse event;
[S 414/2023 wef 26/06/2023]
(n)
date and time of death (if the patient is deceased).
(4) A licensee must ensure that every patient health record —
(a)
accurately and clearly sets out any follow‑up action identified by the licensee or any personnel as being appropriate and necessary for the patient; and
(b)
subject to paragraph (5), contains accurate information about whether that follow‑up action is taken, and if no follow-up action is taken, the reason for the failure to take that follow-up action.
(5) Paragraph (4)(b) does not apply to a licensee who provides a blood banking service, clinical laboratory service, cord blood banking service, human tissue banking service, nuclear medicine service or radiological service.
[S 414/2023 wef 26/06/2023]
Protection of patient health records
38.—(1) A licensee must keep every patient health record confidential and ensure that —
(a)
the confidentiality, integrity and security of every patient health record is maintained at all times; and
(b)
every personnel handling any patient health record is aware of his or her role and responsibility in maintaining the confidentiality, integrity and security of the records.
(2) In addition, where any information in patient health records is in the form of an extract or aggregated compilation, the licensee must ensure that the confidentiality, integrity and security of the information in the extract or aggregated compilation is maintained at all times.
(3) A licensee must —
(a)
implement adequate safeguards and appropriate protocols and processes to protect the patient health records against accidental or unlawful loss, modification or destruction, or unauthorised access, disclosure, copying, use or modification;
(b)
periodically monitor and evaluate the safeguards, protocols and processes mentioned in sub‑paragraph (a) to ensure that they are effective and being complied with by the staff involved in handling the patient health records; and
(c)
take reasonable care in the disposal or destruction of the patient health records so as to prevent unauthorised access to the records.
Continuity of care where licensee intends to cease provision of licensable healthcare service or transfer care of patient to another licensee
39.—(1) Where a licensee intends to cease the provision of any licensable healthcare service or transfer the care of a patient to another licensee, the firstmentioned licensee must, prior to such cessation or transfer, ensure that all reasonable measures are taken to ensure the continuity of care of every affected patient, such as but not limited to the following:
(a)
inform the patient of the cessation or transfer of care (as the case may be) within a reasonable period before the cessation or transfer of care, as the case may be;
(b)
consult the patient about the transfer or disposal of his or her patient health record;
(c)
transfer the patient health record or give a detailed medical report of the patient to —
(i)
the licensee that is taking over the care of the patient; or
(ii)
the patient or his or her authorised representative, upon request by the patient or authorised representative, as the case may be.
(2) In this regulation, a patient’s authorised representative means any of the following persons:
(a)
if the patient is a child — the patient’s parent, adoptive parent, step‑parent or guardian;
(b)
if the patient lacks capacity within the meaning of section 4 of the Mental Capacity Act 2008 —
(i)
a deputy appointed or deemed to be appointed for the person by the court under that Act with power in relation to the person for the purposes of these Regulations; or
(ii)
a donee under a lasting power of attorney registered under that Act with power in relation to the patient for the purposes of these Regulations;
(c)
if the patient is an adult who has capacity — a person whom the patient has authorised to act on the patient’s behalf for any matter (including legal proceedings) that requires information in his or her patient health record.
