# The Nursing Homes Registration (Scotland) Regulations 1990, Section 7: Medical record of each patient


(1) The person registered shall maintain or cause to be maintained in respect of each patient from date of admission to date of discharge a self-contained medical record which shall include the following particulars:—
(a) the patient’s name, address, date of birth and date of admission;
(b) an informative daily statement of the patient’s health and condition;
(c) a note of every medical or surgical investigation, and of every surgical operation, carried out in or under the auspices of the nursing home between the said dates; and
(d) a note of every course of treatment administered to the patient in or under the auspices of the nursing home between the said dates, including treatment prescribed by a medical or dental practitioner.
(2) In the case of a maternity home, the record maintained under paragraph (1) in respect of a maternity patient shall include a record in respect of every child born in the home to that patient, and such record shall include the following particulars of every child:—
(a) the name and date of birth;
(b) the weight and condition at birth;
(c) an informative daily statement of health and condition; and
(d) details of every paediatric examination carried out in or under the auspices of the nursing home which involves any of the following procedures:—
(i) examination for congenital abnormalities including congenital dislocation of the hip;
(ii) measurement of the circumference of the head;
(iii) measurement of length;
(iv) screening for phenylketonuria and neonatal hypothyroidism.
(3) Every record maintained in pursuance of this regulation shall be subject to the provisions of regulation 11(3) and shall be retained at the nursing home by the person currently registered for a minimum period of 3 years from the date of death or discharge of the patient.

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Source: https://www.legislation.gov.uk/uksi/1990/1310/section/7 (the official version)
Page: https://openlegislation.uk/nursing-homes-registration-scotland-regulations-1990/section-7
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.