jswizzle3737/ontario_laws_and_regs huggingface dataset:
1.1 (1) Subject to subsection (2), for the purposes of the Act and this Regulation, a “physician” includes a person who is exempted from subsections 9 (1) and (3) of the Medicine Act, 1991. O. Reg. 206/23, s. 2. (2) For the purposes of section 37 of the Act, a “physician” also includes a person who meets all of the requirements in a regulation made under the Medicine Act, 1991 to be exempted from subsections 9 (1) and (3) of that Act, except for the requirement to provide professional services in a public hospital, the University of Ottawa Heart Institute or a long-term care home. O. Reg. 206/23, s. 2. Board
3. Every administrator is responsible to the board of the hospital of which the administrator has charge, for taking such action as the administrator considers necessary to ensure compliance with the Act, the regulations and the by-laws of the hospital.  R.R.O. 1990, Reg. 965, s. 3. By-laws
5. (1) Every board shall establish a fiscal advisory committee comprised of, (a) the administrator; (b) if there is a dental staff, only one person representing both the medical staff and the dental staff; (c) if there is no dental staff, one person representing the medical staff; (d) the chief nursing executive or another person representing nurses who are managers; (e) one person representing staff nurses; and (f) such other persons as are elected or appointed in accordance with the by-laws of the hospital.  R.R.O. 1990, Reg. 965, s. 5 (1); O. Reg. 64/03, s. 4. (2) The fiscal advisory committee shall make recommendations to the board with respect to the operation, use and staffing of the hospital.  R.R.O. 1990, Reg. 965, s. 5 (2). (3) The chair of the fiscal advisory committee shall be the administrator or a person designated by the administrator.  R.R.O. 1990, Reg. 965, s. 5 (3). Medical Staff
6. (1) Every medical staff shall hold at least four meetings in each fiscal year of the hospital, one of which shall be the annual meeting.  R.R.O. 1990, Reg. 965, s. 6 (1). (2) The first meeting of the medical staff shall be at a time and a place fixed by the board.  R.R.O. 1990, Reg. 965, s. 6 (2). (3) At the first meeting of the medical staff and at each annual meeting thereafter, the medical staff shall, (a) fix a time and place for, (i) the next annual meeting, and (ii) the meetings of the medical staff before the next annual meeting; and (b) elect from among its members, a president, a vice-president and a secretary.  R.R.O. 1990, Reg. 965, s. 6 (3). Medical Advisory Committee
7.1 (1) If a hospital’s by-laws provide for a nursing advisory committee, the committee shall be comprised of, (a) the chief nursing executive; and (b) such other members of the nursing staff as are elected or appointed in accordance with the hospital’s by-laws.  O. Reg. 64/03, s. 6. (2) In subsection (1), “nursing staff” means, with respect to a hospital, all nurses employed or otherwise engaged by the hospital to provide services in the hospital and all members of the hospital’s extended class nursing staff, and includes nurses who are managers and the chief nursing executive for the hospital.  O. Reg. 64/03, s. 6. (3) The nursing advisory committee shall carry out such duties as may be established by by-law.  O. Reg. 64/03, s. 6. Fiscal Year and Annual Meeting
8. Every hospital shall have a fiscal year that ends with the 31st day of March in each year.  R.R.O. 1990, Reg. 965, s. 8.
9. (1) Every hospital shall hold an annual meeting between the 1st day of April and the 31st day of July in each year on a day fixed by the board.  R.R.O. 1990, Reg. 965, s. 9. (2) Despite subsection (1), the Minister may direct that the annual meeting be held at another time, and the board shall comply with the direction of the Minister. O. Reg. 213/20, s. 1. Inspectors
10. (1) An inspector without a warrant at any time may enter upon the premises of a hospital to make an inspection to ensure that the provisions of the Act and this Regulation are being complied with.  R.R.O. 1990, Reg. 965, s. 10 (1). (2) Upon an inspection under this section, the inspector, (a) is entitled at any reasonable time to free access to all books of account, documents, bank accounts, vouchers, correspondence and records, including payroll records, records of staff hours worked, records of personal health information and any other records that are relevant for the purposes of the inspection or required to be kept under the Act or this Regulation; (b) upon giving a receipt therefor and showing the designation issued by the Minister, may remove any material referred to in clause (a) that relates to the purpose of the inspection in order to make a copy thereof, provided that the copying is carried out with reasonable dispatch and the material in question is promptly thereafter returned to the person from whose possession it was removed; (c) may examine or test samples of substances to ensure that the regulations are being complied with; and (d) upon giving a receipt therefor and showing the designation issued by the Minister, may remove a substance or a sample of a substance referred to in clause (c) in order to conduct further tests, for any purpose reasonably necessary to carry out effectively the purposes of the Act and this Regulation.  R.R.O. 1990, Reg. 965, s. 10 (2); O. Reg. 332/04, s. 2. (3) Clause (2) (b) does not apply where a copy can be made on the premises of the hospital unless the inspector has reason to believe that the material in question cannot be copied with reasonable dispatch or is likely to be altered.  R.R.O. 1990, Reg. 965, s. 10 (3). (4) No person shall obstruct the inspector or withhold, destroy, conceal or refuse to furnish any information or thing required by the inspector for the purposes of the inspection.  R.R.O. 1990, Reg. 965, s. 10 (4). Obtaining Drugs
11. (1) No person shall be admitted to a hospital as a patient except, (a) on the order or under the authority of a physician who is a member of the medical staff; (a.1) on the order or under the authority of a registered nurse in the extended class who is a member of the extended class nursing staff; (b) on the order or under the authority of an oral and maxillofacial surgeon who is a member of the dental staff; (b.1) if the person is being admitted for treatment by a dentist who is a member of the dental staff other than an oral and maxillofacial surgeon, on the joint order of the dentist and a physician who is a member of the medical staff; or (c) on the order or under the authority of a midwife who is a member of the midwifery staff.  O. Reg. 761/93, s. 4; O. Reg. 346/01, s. 2 (1); O. Reg. 216/11, s. 3 (1); O. Reg. 159/17, s. 2. (2) No physician, registered nurse in the extended class, dentist or midwife shall order the admission of a person to a hospital unless, in the opinion of the physician, registered nurse in the extended class, dentist or midwife, it is clinically necessary that the person be admitted.  O. Reg. 216/11, s. 3 (2). (3) No person shall be registered in a hospital as an out-patient except, (a) on the order or under the authority of a member of the medical staff, midwifery staff or extended class nursing staff; (b) on the order or under the authority of a member of the dental staff who is an oral and maxillofacial surgeon; (b.1) in the case of a person who is an out-patient solely for the purpose of attending a dental clinic in a hospital, on the order or under the authority of a member of the dental staff; or (c)  Revoked:  O. Reg. 64/03, s. 7 (2). O. Reg. 45/98, s. 4; O. Reg. 346/01, s. 2 (2); O. Reg. 64/03, s. 7; O. Reg. 159/17, s. 2. Register Number
12. (1) Every administrator shall ensure that each patient who is admitted to the hospital is issued a register number.  R.R.O. 1990, Reg. 965, s. 12 (1). (2) A baby born alive in a hospital shall at the time of birth be deemed to be a patient admitted to a hospital for the purposes of subsection (1).  R.R.O. 1990, Reg. 965, s. 12 (2). (3) Register numbers shall be issued to patients by, (a) assigning the number “1” to the first patient admitted in the fiscal year and thereafter assigning numbers in the order of admission; and (b) adding after the number given under clause (a), a virgule and the last two digits of the number of the year in which it is issued.  R.R.O. 1990, Reg. 965, s. 12 (3). (4) A patient shall retain the same register number until the patient is discharged from the hospital.  R.R.O. 1990, Reg. 965, s. 12 (4). Identification Number
13. (1) Every administrator shall ensure that the contents of each patient’s records of personal health information and all other health information in the hospital relating to the patient bear an identification number for the patient.  R.R.O. 1990, Reg. 965, s. 13 (1); O. Reg. 332/04, s. 3. (2) For the purposes of subsection (1), a register number issued to a patient under section 12 may be used as the patient’s identification number on the health information pertaining to the admission for which the register number was issued.  R.R.O. 1990, Reg. 965, s. 13 (2). (3) Where a hospital does not use a register number as an identification number, the administrator shall ensure that the health information pertaining to each separate admission of the patient can be identified by other means.  R.R.O. 1990, Reg. 965, s. 13 (3). Dangerous or Infectious Patient
14. (1) A physician, a registered nurse in the extended class, an oral and maxillofacial surgeon or a midwife who knows or suspects that a person being admitted to the hospital on the physician’s, registered nurse in the extended class’s, oral and maxillofacial surgeon’s or midwife’s order is or may become dangerous to himself or herself or to other persons, shall forthwith notify the administrator concerning the patient.  O. Reg. 216/11, s. 4 (1). (2) An attending physician, attending dentist, attending midwife or attending registered nurse in the extended class who knows or suspects that his or her patient is suffering from an infectious disease or condition shall forthwith notify the administrator and either an infection control officer or an infection control nurse about the patient.  O. Reg. 45/98, s. 5; O. Reg. 216/11, s. 4 (2).
15. Every board shall ensure that the hospital provides for the isolation of patients as is necessary in the circumstances.  R.R.O. 1990, Reg. 965, s. 15. Discharge of Patient from Hospital
16. (1) If a patient is no longer in need of treatment in the hospital, one of the following persons shall make an order that the patient be discharged and communicate the order to the patient: 1. The attending physician, registered nurse in the extended class or midwife or, if the attending dentist is an oral and maxillofacial surgeon, the attending dentist. 2. A member of the medical, extended class nursing, dental or midwifery staff designated by a person referred to in paragraph 1. O. Reg. 346/01 s. 4; O. Reg. 216/11, s. 5; O. Reg. 159/17, s. 2. (2) Where an order has been made with respect to the discharge of a patient, the hospital shall discharge the patient and the patient shall leave the hospital on the date set out in the discharge order. R.R.O. 1990, Reg. 965, s. 16 (2). (3) Despite subsection (2), the administrator may grant permission for a patient to remain in the hospital for a period of up to twenty-four hours after the date set out in the discharge order. R.R.O. 1990, Reg. 965, s. 16 (3). (3.1) If a discharged patient remains in the hospital for more than 24 hours after the date set out in the discharge order, the hospital shall charge the patient a fee of $400 for every day that the patient remains in the hospital following the expiry of that 24-hour period. O. Reg. 486/22, s. 1. (4) Without limiting the generality of subsection (1), a patient is no longer in need of treatment in the hospital for the purposes of that subsection if, (a) the patient is designated as an alternate level of care patient in accordance with subsection (5); and (b) the patient’s admission to a long-term care home has been authorized in accordance with section 60.1 of the Fixing Long-term Care Act, 2021 and any applicable regulations made under that Act. O. Reg. 485/22, s. 1. (5) An attending clinician may designate a patient of the attending clinician as an alternate level of care patient if, in the clinician’s opinion, the patient does not require the intensity of resources or services provided in the hospital care setting. O. Reg. 485/22, s. 1. (6) For the purposes of subsection (5), “attending clinician” means a person entitled to make an order under subsection (1). O. Reg. 485/22, s. 1. Report of Death
17. (1) When a patient dies in a hospital, the attending physician or registered nurse in the extended class shall cause a copy of the medical certificate of death required under the Vital Statistics Act to be filed in the medical record pertaining to the patient.  O. Reg. 216/11, s. 6. (2) Where the Vital Statistics Act requires a coroner to complete the medical certificate of death and the coroner does not provide the attending physician or registered nurse in the extended class with a copy of the medical certificate of death, the attending physician or registered nurse in the extended class shall, (a) complete a report in the form entitled “Certificate of Death – Form 1”, dated April 2017 and available on the website of the Government of Ontario Central Forms Repository under the listing for the Ministry of Health and Long-Term Care; and (b) cause a copy of the report to be filed in the medical record pertaining to the patient. O. Reg. 159/17, s. 4. Physician or Dentist Unable to Perform Duties
18. (1) Where a person who is a member of the medical, dental, midwifery or extended class nursing staff is unable for any reason to perform his or her professional duties with respect to a patient in the hospital, the person shall arrange for another member of the medical, dental, midwifery or extended class nursing staff, as may be appropriate, to perform the person’s duties.  O. Reg. 761/93, s. 8; O. Reg. 45/98, s. 6; O. Reg. 159/17, s. 2. (2) Where a person is unable to perform his or her duties as set out in subsection (1), the person shall note, where another person assumes his or her duties, the name of the person assuming the duties in the patient’s medical record.  R.R.O. 1990, Reg. 965, s. 18 (2). (3) Where an administrator believes that a person who is a member of the medical, dental, midwifery or extended class nursing staff is unable to perform the person’s professional duties with respect to a patient in the hospital, the administrator shall notify, (a) the chief of staff or the chair of the medical advisory committee; (b) in the case of a member of the medical staff, the president or the secretary of the medical staff; and (c) in the case of a member of the extended class nursing staff, the chief nursing executive.  O. Reg. 64/03, s. 8; O. Reg. 159/17, s. 2. Records of Personal Health Information
21. (1) Every board shall determine the procedure to be followed by the hospital for the destruction of records of personal health information or photographs of any of them.  R.R.O. 1990, Reg. 965, s. 21 (1); O. Reg. 332/04, s. 6 (1). (2) Where records of personal health information or photographs of any of them are destroyed, the administrator shall forthwith make and authenticate a written statement that sets out, (a) the names of the patients to whom the records of personal health information or photographs thereof refer; and (b) the date and manner of the destruction and whether or not the destruction was carried out in accordance with the procedures determined by the board.  R.R.O. 1990, Reg. 965, s. 21 (2); O. Reg. 332/04, s. 6 (2, 3). (3) The administrator shall retain in the hospital all statements made under subsection (2) in accordance with the by-laws of the hospital.  R.R.O. 1990, Reg. 965, s. 21 (3). Disclosure of Records
22.1 (1) Where a direction issued under section 6 of the Act directs a hospital to transfer or relinquish the operation and management of all of its programs and services to another hospital or hospitals, the hospital that is subject to the direction shall transfer its records of personal health information to the transferee hospitals specified in the direction in a manner that will protect the privacy of the records.  O. Reg. 150/98, s. 1; O. Reg. 332/04, s. 8 (1). (2) Where a direction issued under section 6 of the Act directs a hospital to transfer or relinquish the operation and management of part of its programs and services to another hospital or hospitals, the hospital that is subject to the direction shall transfer the records of personal health information associated with the transferred programs and services to the transferee hospitals specified in the direction in a manner that will protect the privacy of the records.  O. Reg. 150/98, s. 1; O. Reg. 332/04, s. 8 (2).
22.2 (1) A hospital, when requested to do so by the Minister in writing, shall disclose information concerning indicators of the quality of health care provided by the hospital, as specified by the Minister, that relate to any or all of the following: 1. Diagnoses of hospital-acquired infections. 2. Activities undertaken to reduce hospital-acquired infections. 3. Mortality.  O. Reg. 257/08, s. 1. (2) The hospital shall disclose the information under subsection (1) through the hospital’s website and through such other means and to such other persons as the Minister may direct.  O. Reg. 257/08, s. 1. (3) In this section, “information” does not include identifying information as defined in subsection 4 (2) of the Personal Health Information Protection Act, 2004.  O. Reg. 257/08, s. 1.
23. A hospital, when requested to do so by the Minister, shall provide information, (a) from records of personal health information including x-ray films, to Ontario Health for purposes related to the oversight and co-ordination of Ontario’s cancer care and renal care systems and the administration of access to care and wait times initiatives; (b) from records of personal health information, to a person for purposes of information and data collection, organization and analysis; (c) from records of personal health information, to a physician assessor appointed by the Ministry, for the purposes of evaluating applications to the Underserviced Area Program; and (d) from records of reviews of critical incidents conducted pursuant to a system established under subsection 2 (3.1), to a person for purposes of conducting analyses and disseminating information in order to support quality improvement activities. O. Reg. 332/04, s. 9; O. Reg. 484/16, s. 2; O. Reg. 63/20, s. 1.
23.1 Revoked:  O. Reg. 332/04, s. 9.
23.2 (1) A hospital shall provide information from records of personal health information to the following persons for the purposes of the diagnosis of persons who may have contracted SARS and the investigation, prevention, treatment and containment of SARS: 1. The Chief Medical Officer of Health within the meaning of the Health Protection and Promotion Act. 2. A medical officer of health within the meaning of the Health Protection and Promotion Act. 3. A physician designated by the Chief Medical Officer of Health.  O. Reg. 201/03, s. 1; O. Reg. 332/04, s. 10. (2) In subsection (1), “SARS” means severe acute respiratory syndrome.  O. Reg. 201/03, s. 1. Orders for Treatment
24. (1) Every order for treatment or for a diagnostic procedure of a patient shall, except as provided in subsection (2), be in writing and shall be dated and authenticated by the physician, dentist, midwife or registered nurse in the extended class giving the order.  O. Reg. 64/03, s. 10. (2) A physician, dentist, midwife or registered nurse in the extended class may dictate an order for treatment or for a diagnostic procedure by telephone to a person designated by the administrator to take such orders.  O. Reg. 64/03, s. 10. (3) Where an order for treatment or for a diagnostic procedure has been dictated by telephone, (a) the person to whom the order was dictated shall transcribe the order, the name of the physician, dentist, midwife or registered nurse in the extended class who dictated the order, the date and the time of receiving the order and shall authenticate the transcription; and (b) the physician, dentist, midwife or registered nurse in the extended class who dictated the order shall authenticate the order on the first visit to the hospital after dictating the order.  O. Reg. 761/93, s. 11; O. Reg. 45/98, s. 3.
26. Revoked:  O. Reg. 17/95, s. 4. Sterilization of Persons under Sixteen
27. (1) No person shall perform a surgical operation for the purpose of rendering a patient incapable of insemination or of becoming pregnant where the patient is under the age of sixteen years.  R.R.O. 1990, Reg. 965, s. 27 (1). (2) Subsection (1) does not apply where the attending physician is of the opinion that the surgical operation is medically necessary for the protection of the physical health of the patient.  R.R.O. 1990, Reg. 965, s. 27 (2). Anaesthesia
28. (1) No person shall administer an anaesthetic to a patient unless the person responsible for administering the anaesthetic, (a) takes the medical history and performs the physical examination of the patient that are necessary to enable the person to evaluate the condition of the patient and to choose a suitable anaesthetic, in accordance with professional standards; and (b) enters or causes to be entered and authenticates on the medical record of the patient the data relevant to safely administering the anaesthetic for the proposed procedure from, (i) the patient’s history, (ii) the results of any laboratory tests the person considers necessary, and (iii) a physical examination. O. Reg. 289/19, s. 3. (2) Subsection (1) does not apply where the person responsible for administering the anaesthetic and the attending physician are of the opinion that a delay for the purpose of complying with that subsection would endanger the life or a limb or vital organ of the patient. O. Reg. 289/19, s. 3. (3) Where a person intends to administer an anaesthetic without complying with subsection (1) and the person responsible for administering the anaesthetic and the attending physician are of the opinion that a delay for the purpose of complying with that subsection would endanger the life or a limb or vital organ of the patient, they shall, as soon as practicable, jointly prepare and authenticate a statement that sets out that opinion. O. Reg. 289/19, s. 3. (4) Where an anaesthetic to which subsection (1) applies is administered to a patient, the person responsible for administering the anaesthetic shall prepare an anaesthetic report or make or cause to be made an entry on the medical record with respect to the patient that shows, as applicable, (a) the medications given to the patient in contemplation of the administration; (b) the patient airway, circuit and monitors used on the patient; (c) the anaesthetic agents used, the methods of administration of the agents and the proportions or concentrations of all agents administered by inhalation to the patient; (d) the names, quantities and times of all drugs given by injection to the patient; (e) the duration of the anaesthesia on the patient; (f) the estimated fluid loss of the patient; (g) the quantities and type of all blood products and other fluids administered intravenously to the patient during the operation; and (h) the vital signs of the patient before, during and after anaesthesia. O. Reg. 289/19, s. 3. Surgery
29. (1) No surgeon shall perform a surgical operation on a patient unless the surgeon, (a) takes a medical history and performs a physical examination of the patient sufficient to enable the surgeon to make a diagnosis; and (b) enters or causes to be entered and authenticates on the medical record of the patient, (i) a history of the present disability or disease and any previous medical history relevant to that disability or disease, (ii) a statement of the findings on the physical examination and the diagnosis, and (iii) the results of any laboratory tests the surgeon considers necessary. O. Reg. 289/19, s. 3. (2) Where anaesthetic is to be administered to the patient, the entering and authentication required under clause (1) (b) must be performed before the anaesthetic is administered, except under the circumstances described in subsection 28 (2). O. Reg. 289/19, s. 3. (3) Every surgeon who performs a surgical operation in a hospital shall prepare, or cause to be prepared by a person qualified to do so, a written description of the operative procedure at the operation and findings and diagnosis made at the operation with respect to the patient, as the case requires. O. Reg. 289/19, s. 3. (4) The written description referred to in subsection (3) shall be authenticated by the surgeon performing the operation and the person making the description. O. Reg. 289/19, s. 3.
30. (1) Every surgeon who performs an operation on a patient is responsible for directing the post-operative care of the patient until responsibility for the care of the patient is assumed by another physician.  R.R.O. 1990, Reg. 965, s. 30 (1). (2) Every person responsible for the administration of an anaesthetic to a patient is responsible for directing the post-anaesthetic care of the patient. O. Reg. 289/19, s. 4.
31. (1) Where tissues are removed from a patient during an operation or curettage, the surgeon performing the operation or curettage shall cause all tissues removed from the patient to be sent, together with a short history of the case and a statement of the findings of the operation, to a laboratory for examination and report.  R.R.O. 1990, Reg. 965, s. 31 (1). (2) Despite subsection (1), the following tissue shall not be sent to a laboratory unless the surgeon performing the operation or curettage requests an examination and report on such tissue: 1. Where the tissue removed is an arm, finger, foot, hand, hemorrhoid, lens, leg, prepuce, tonsil, toe, toenail or tooth. 2. Where the tissue removed is from reconstructive joint surgery related to a degenerative condition. O. Reg. 117/23, s. 1.
32. Where blood is taken from any person for use in a transfusion, the person taking the blood shall record or cause to be recorded, (a) the name, address, blood-grouping and Rh factor typing of the person from whom the blood was taken; (b) the date of taking of the blood; (c) the amount of blood taken; and (d) the result of any tests made on a sample of the blood taken for the transfusion.  R.R.O. 1990, Reg. 965, s. 32. Charges for Special Services
33. (1) No hospital other than a Group M Hospital within the meaning of Regulation 964 of the Revised Regulations of Ontario, 1990, (Classification of Hospitals) shall charge or accept payment from any other hospital for the performance for the other hospital of a computerized axial tomography scan.  R.R.O. 1990, Reg. 965, s. 33 (1). (2) No hospital other than a Group N Hospital within the meaning of the said Regulation 964 shall charge or accept payment from any other hospital for the performance for the other hospital of a magnetic resonance imaging.  R.R.O. 1990, Reg. 965, s. 33 (2). (3) No hospital other than a Group P Hospital within the meaning of the said Regulation 964 shall charge or accept payment from any other hospital for the performance for the other hospital of extra corporeal shock wave lithotripsy.  R.R.O. 1990, Reg. 965, s. 33 (3).
34. (1) Where in this Regulation or under by-laws of a hospital a notation, report, record, order, entry, signature or transcription is required to be entered, prepared, made, written, kept or copied, the entering, preparing, making, writing, keeping or copying may be done by such electronic or optical means or combination thereof as may be authorized by the board.  R.R.O. 1990, Reg. 965, s. 34 (1). (2) The board shall ensure that the electronic or optical means referred to in subsection (1) is so designed and operated that the notation, report, record, order, entry, signature or transcription is secure from loss, tampering, interference or unauthorized use or access.  R.R.O. 1990, Reg. 965, s. 34 (2). Definition of Hospital Subsidiary
35. (1) For the purposes of subsection 32 (4) of the Act, “hospital subsidiary” means a corporation that is controlled directly or indirectly in any manner by one or more hospitals.  O. Reg. 552/96, s. 1; O. Reg. 183/98, s. 2 (1). (2) Revoked:  O. Reg. 183/98, s. 2 (2). Dissolution of Hospital Corporations
36. A corporation that owns or operates a hospital or that has previously owned or operated a hospital shall not take any action that may result in the dissolution of the corporation unless the Minister approves of the action.  O. Reg. 552/96, s. 1. Form 1 Revoked: O. Reg. 159/17, s. 5. FormS 2, 3 Revoked:  O. Reg. 761/93, s. 14.  Français