Singapore legislation
Regulation 37
Regulation 37
Information to be contained in patient health records
Subregulation 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.
Subregulation 2
A patient health record must contain all of the following information relating to the patient:
name;
identification number or passport number;
gender;
date of birth.
Subregulation 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:
residential address;
ethnic group;
date and time of every consultation, referral, admission, investigation and discharge;
admission forms and patient registration number for the visit, consultation or admission;
medical history, referral documents and declaration forms relating to the patient’s health or medical history;
clinical findings and progress notes;
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;
(gb)the date of and reason for each medical certificate issued to the patient;
(gc)any consent or acknowledgment forms;
allergies and other factors requiring special consideration;
results of laboratory tests;
reports of X-rays and other investigations;
vaccinations;
consent forms;
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;
(mb)financial counselling forms;
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;
date and time of death (if the patient is deceased).
Subregulation 4
A licensee must ensure that every patient health record —
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
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.
Subregulation 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.