S.L. 458.23 Art. 11Registers, receipts, case records.

(1) Proper records are to be kept of patients treated at the clinic -

(a) in respect of each patient, in a register showing: - the name, address, date of birth and a legally valid identification document of the patient and, where the patient has no legally valid identification document, the passport number shall be included together with the country of issue, if such patient has a passport; - the name, address, a legally valid identification document number and telephone number of the patient’s next of kin or of any person authorised to act on the patient’s behalf; - the name and address of the patient’s medical practitioner; - the date when and the time during which the patient was admitted and the date of discharge or transfer to a clinic or other place as may be applicable; - if the patient died in the clinic, the date, time and cause of death; - in the case of a child, where applicable, the name and address of the school he attends or has attended before being admitted to the clinic;

(b) a separate register of all surgical operations performed in the clinic: such register shall include in respect of each operation, the date and time of such operation, the patient’s name, a legally valid identification document or passport number as may be applicable or as provided for under the preceding paragraph, the clinic case history number, the name of the medical or dental practitioner who performed the operation, and, where applicable, the name of any other practitioner assisting him, as well as the name of the anesthetist in attendance;

(c) a separate case record of every patient which shall contain an adequate updated statement of the patient’s health and condition and a note of any investigation and details of surgical operations carried out and treatment given, including the anaesthetic record sheet.

(d) a record of each member of the staff employed, which record shall include the name, date of birth, a legally valid identification document number, grade and dates of employment at the clinic, and, in respect of nursing staff, details of their qualifications. Such records shall, as far as reasonably practicable, include the times when individual members of the nursing staff as well as the person or persons in charge were on duty;

(e) a record of the following: - all fire practices; - all fire alarm tests, results and action taken where applicable; - the maintenance carried out on medical, surgical and nursing equipment in the clinic;

(f) such other records as the Minister may, from time to time, require to be kept.

(2) All records referred to in subregulation (1), other than patient case records, shall be retained for a period of not less than two years after the last entry made therein, and shall be open for inspection by an authorised officer or by such authority as may have such power under any law.

(3) Patient case records shall be retained and shall not be destroyed except with the approval of the Minister.

(4) It shall be the duty of the person in charge of the clinic to ensure proper keeping and storage of records and, subject to the provisions of these regulations and to any other law relating to confidentiality of records, to limit disclosure only to persons entitled to access to such information.

(5) All records shall be legibly entered in full and in proper order. Any alterations, corrections or deletions shall be initialled by the person making such alteration, correction or deletion.

(6) Notwithstanding the provisions of the preceding sub-regulations, computer records may, under such conditions as the Minister may impose in the licence certificate, be acceptable, provided always that a hard copy of the day’s entries are made each day and filed in chronological order: Provided that such alternative shall not, in the case where the Minister directs that a copy of the entries be sent regularly to the Ministry and/or the department, be construed as any acceptance of any irregularity carried out at the clinic on the pretext that the Ministry and/or the department had been regularly informed.