2023 Laws not yet authenticated through a Commencement Order

Revised Laws of Saint Lucia (2023)

12.   Preparation of Case Records

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    (1)   A medical record indicating the history with a report of the physical examination and a provisional diagnosis shall be written up by the examining physician within 36 hours of the patient's admission to the hospital.

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    (2)   The attending physician, after consultation with any other consultant and in keeping with the requisite ethical standards of the practice of medicine and surgery is responsible for the preparation of a complete medical record of every patient in a private hospital, which record shall contain inter alia, identification, complete present history, family history, physical examination, special reports including reports of consultation, laboratory tests and X-ray examinations, provisional diagnosis, medical or surgical treatment pathological findings, progress notes, reports of operations and anaesthesia final diagnosis, conditions of discharge and follow up records.

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    (3)   Every report of any consultant or any other person shall state clearly the particulars of the consultant or other person and shall be signed by the consultant or other person as the case may be.

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    (4)   The superintendent of every private hospital shall retain and preserve in a place of safe keeping all records relating to every patient in the hospital.