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.
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(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;
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(e)
medical history, referral documents and declaration forms relating to the patient’s health or medical history;
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(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;
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(gb)
the date of and reason for each medical certificate issued to the patient;
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(gc)
any consent or acknowledgment forms;
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(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;
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(mb)
financial counselling forms;
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(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;
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(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.