Health Services (Health Service Establishments) Regulations 2024

the patient's unit record number;

the patient's name, address, date of birth and sex;

the name and contact details of a relative or friend nominated by the patient;

relevant clinical details of the patient including the following—

clinical history on admission;

progress notes whenever the patient is receiving health services from the health service establishment, including notes of any incidents that are clinically relevant;

any medication ordered or given;

known allergies and drug sensitivities;

current medication;

clinical risk assessments conducted before the patient receives a health service, including a pre-admission assessment conducted in accordance with regulation 25;

results of any relevant diagnostic tests;

if a procedure is carried out on the patient, the following information—

the consent form for the procedure and anaesthesia;

the date of the procedure;

the name and signature of each registered health practitioner carrying out the procedure;

the type of procedure carried out;

the pre-procedure check list by the attending practitioner or by the assisting nurse;

administered drugs and dosages;

a record of any monitoring undertaken;

a record of any intravenous fluids administered;

a procedure room report including any procedure findings;

the final diagnosis of the patient on discharge.