Private Health Facilities Regulation 2024
30Clinical records
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30 Clinical records
30 Clinical records
(1) A facility must have a clinical record for each patient at the facility.
(2) The clinical record must include the following—
(a) the date and time of the patient’s arrival,
(b) details of the patient’s presenting symptoms and condition,
(c) the triage category allocated when the patient is first assessed,
(d) details of significant clinical, laboratory and radiological findings,
(e) if the patient is treated—details of the treatment,
(f) if the patient is given follow-up directions—details of the directions,
(g) the date and time of the patient’s departure,
(h) the identity and signature of the attending medical officer.