Private Hospitals and Day Procedure Centres Act 1988 Day Procedure Centres Regulation 1990 (1990-434) [GG No 82 of 29.6.1990] (NSW)

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PRIVATE HOSPITALS AND DAY PROCEDURE CENTRES

ACT 1988 - REGULATION

(Day Procedure Centres Regulation 1990)

NEW SOUTH WALES

[Published in Gazette No. 82 of 29 June 1990]

HIS Excellency the Governor, with the advice of the Executive

Council, and in pursuance of the Private Hospitals and Day Procedure Centres Act 1988, has been pleased to make the Regulation set forth hereunder.

PETER COLLINS,

Minister for Health.

PART 1 - PRELIMINARY

Citation

1. This Regulation may be cited as the Day Procedure Centres Regulation 1990.

Commencement

2. This Regulation commences on 1 September 1990.

Application

3. (1) This Regulation applies to and in respect of all day procedure centres.

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(2) For the purposes of the definition of "day procedure centre'' in section 3 (1) of the Act, the prescribed treatment and circumstances

are:

(a)	surgical treatment provided in circumstances that involve the administration of a general, spinal, epidural or regional block anaesthetic or intravenous sedative (otherwise than for the purpose of simple sedation); or
(b)	endoscopic treatment provided in circumstances that involve the administration of a general anaesthetic or intravenous sedative (otherwise than for the purpose of simple sedation); or
(c)	any other treatment provided in circumstances that involve haemofiltration, haemoperfusion or continuous intravenous infusion of more than one cytotoxic agent,

other than emergency treatment provided by a medical practitioner or dentist in circumstances that render impracticable the transfer of the patient to a hospital or day procedure centre.

De finitions

4. (1) In this Regulation:
"admission form'' means an admission form referred to in clause 14;

"approved" means approved for the time being by the Director-General, either generally or in any particular case or class of cases;

"child" means a person who is under the age of 10 years;

"clinical records" means clinical records referred to in Part 6 of

Schedule 1;

"morbidity form'' means a morbidity form referred to in clause 14; ''nursing supervisor" means a person holding office or acting as a

nursing supervisor in the Department of Health;

"patient's representative" means:

(a) if the patient is under the age of 14 years - a parent having

legal custody of the patient; or

(b)	if the patient is under guardianship - the patient's guardian; or
(c)	if the patient has died - the executor or administrator of the

patient's estate;

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"simple sedation" means a technique in which the use of a drug or

drugs produces a state of depression of the central nervous system

enabling treatment to be carried out in such a manner:

(a)	that verbal contact with the patient can be maintained throughout the period of sedation; and
(b)	that the drugs and techniques used have a margin of safety wide enough to render unintended loss of consciousness unlikely;

"the Act" means the Private Hospitals and Day Procedure Centres

Act 1988.

(2) In this Regulation, a reference to a particular class of day procedure centre is a reference to a day procedure centre that is licensed as a day procedure centre of that class.

(3) In this Regulation, a reference to a form is a reference to a form set out in Schedule 2.

PART 2 - LICENSING OF DAY PROCEDURE CENTRES

Licensing standards

5. (1) For the purposes of section 7 of the Act, the standards specified in Schedule 1 are prescribed.

(2) The licensee of a day procedure centre must not fail to conduct the day procedure centre in accordance with the provisions of Schedule 1 applicable to the day procedure centre.

Maximum penalty: 5 penalty units.

(3) The licensee of a day procedure centre is not guilty of an offence

under this clause if the licensee:

(a)	was not aware of the circumstances giving rise to the alleged offence; and
(b)	could not reasonably be expected to have been aware of those circumstances.

(4) A contravention of a provision of Schedule 1 by any person other than the licensee of a day procedure centre does not constitute an offence under this Regulation.

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Applications for licences

6. For the purposes of section 8 of the Act:

(a)	the prescribed form of application is Form 1; and
(b)	the prescribed application fee is $450.

Classes of day procedure centres

7. (1) For the purposes of section 13 of the Act, the following classes of day procedure centres are prescribed:

(a) surgical;
(b) endoscopic.

(2) The licensee of a day procedure centre is not to admit a person

to a day procedure centre for the performance of a surgical procedure

unless the centre is a surgical class day procedure centre.

Maximum penalty 5 penalty units.
(3) The licensee of a day procedure centre is not to admit a person

to a day procedure centre for the performance of an endoscopic procedure unless the day procedure centre is an endoscopic or surgical class day procedure centre.

Maximum penalty 5 penalty units.

Annual licence fees

8. For the purposes of section 17 of the Act, the prescribed annual licence fee is $840.

Transfer of licence

9. For the purposes of section 18 of the Act:

(a)	the prescribed form of application is Form 2; and
(b)	the prescribed application fee is $450.

Alterations or extensions 10. For the purposes of section 19 of the Act, the prescribed form

of application is Form 3.

Application for review of Director-General’s decision

11. For the purposes of section 28 of the Act, the prescribed form of application is Form 4.

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Chief nurse

12. (1) For the purposes of section 41 (1) of the Act, the prescribed qualifications to be held by a registered nurse who carries out the duties of chief nurse of a day procedure centre are:

(a) current registration in New South Wales as a nurse; and

(b) 5 years’ post-basic or post-graduate nursing experience; and

(c) 2 years’ administrative experience in a position of, or more senior than that of, nursing unit manager in a hospital,

or such other qualifications as may be approved.

(2) For the purposes of section 41 (2) of the Act, the prescribed number of days is 7.

(3) A notification under section 41 (3) of the Act is to be in or to the effect of Form 5.

(4) For the purposes of section 41 (4) of the Act, the prescribed particulars in respect of a person who carries out the duties of chief nurse are those required to complete Form 5, together with the person’s curriculum vitae and a copy of the person’s current annual practising certificate.

Register of patients

13. (1) For the purposes of section 44 (1) of the Act, the prescribed form for a register of patients is a series of forms, each form being in or to the effect of Form 6, completed in respect of each patient and maintained in strict admission date order.

(2) For the purposes of section 44 (2) (e) of the Act, the prescribed particulars to be entered in the register of patients are the particulars required to complete Form 6.

(3) For the purposes of section 44 (3) of the Act, a particular required to be entered in the register of patients must be entered:

(a)	in the case of a particular required to complete Part A of Form 6, at the time of admission of the patient; and
(b)	in the case of a particular required to complete Part B of Form 6, at the time the person ceases to be a patient; and

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(c) in either case:

(i)         in such manner as may be directed by the senior nurse on duty at the day procedure centre at the time the particulars are obtained; and

(ii)        subject to subparagraph (i), by hand or by use of an approved electronic data processing system.

Records

14. (1) In addition to the register of patients, the licensee of a day procedure centre must keep, in respect of each patient:

(a) an admission form, in or to the effect of Form 7; and

(b) a morbidity form, in or to the effect of Form 8; and

(c) such other records as are referred to in Schedule 1 .

Maximum penalty 5 penalty units.

(2) Such records may be kept by hand or by use of an approved

electronic data processing system.

PART 3 - MISCELLANEOUS

Evidentiary certificates
15. For the purposes of section 51 of the Act, the following officers of the Department of Health are prescribed officers:

Deputy Director-General;
Executive Director, Service Development and Planning;
Chief Health Officer;
Deputy Chief Health Officer;

Regional Director.

Display of licence

16. The licensee of a day procedure centre must, at all times while the day procedure centre is being conducted, cause to be displayed in a prominent place in the entrance foyer or other place readily visible to visitors the licence for the day procedure centre or a full-size copy of the licence.

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Maximum penalty 5 penalty units.

Information to be furnished with annual licence fee

17. (1) The licensee of a day procedure centre must, when paying an annual licence fee referred to in section 17 of the Act, furnish to the Director-General:

(a) a certificate in or to the effect of Form 9; and

(b) a copy of the chief nurse’s current annual practising certificate.

Maximum penalty: 5 penalty units.
(2) If the licensee is a corporation, the licensee must at the same

time furnish to the Director-General the following particulars:

(a) the full name of the corporation;

(b) the address of the registered office of the corporation;

(c)

the full name, residential address and position of:

(i)	each current director of the corporation;
(ii)	the principal executive officer of the corporation;
(iii)	the secretary or, if there is more than one, each secretary of the Corporation;

(d)

in the case of a corporation limited by shares:

(i)	the types of shares and the number of shares of each type issued;
(ii)	in the case of a private corporation - the full name of, and the number of shares held by, each shareholder;
(iii)	in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;

(e)

if the shares are held by another corporation, the name of the ultimate holding corporation.

Maximum penalty 5 penalty units.

Information to be furnished periodically

18. (1) The licensee of a day procedure centre must, for each month,

furnish to the Director-General a statistical statement in or to the
effect of Form 10.

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Maximum penalty: 5 penalty units.
(2) Such a certificate is to contain the information required to

complete Form 10 and is to be furnished to the Director-General within 14 days after the end of the month to which the information relates.

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SCHEDULE 1 - LICENSING STANDARDS

(Cl. 5)

PART 1 - DESIGN AND CONSTRUCTION OF PREMISES

Ambulance access

1.1.1. A day procedure centre must have adequate access for the emergency transfer of patients by ambulance.

PART 2 - FACILITIES AND EQUIPMENT

Equipment in surgical class day procedure centres

1.2.1. The following equipment is to be provided in a surgical class day procedure

centre and is to be available at all times while the day procedure centre is in use:

(a) an electrosurgical unit;

(b)	adequate instrument sets for elective use; sterile instrument sets available for emergency procedures;
(c)	anaesthetic equipment recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Recommended Minimum Facilities for Safe Anaesthetic Practice in Operating Suites";
(d)	monitoring equipment recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Monitoring During Anaesthesia";
(e)	recovery equipment and drugs recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Guidelines for the Care of Patients Recovering from Anaesthesia Related to Day Surgery".

Equipment in endoscopic class day procedure centres

1.2.2. The following equipment is to be provided in an endoscopic class day

procedure centre and is to be available at all times while the day procedure centre
is in use:

(a)	at least 2 upper gastrointestinal endoscopes;
(b)	at least 2 colonoscopes;
(c)	fluoroscopic facilities, where appropriate;
(d)	an electrosurgical unit;
(e)	anaesthetic equipment recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Recommended Minimum Facilities for Safe Anaesthetic Practice in Operating Suites";
(f)	monitoring equipment recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Monitoring During Anaesthesia";
(g)	recovery equipment and drugs recommended by the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Guidelines

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for the Care of Patients Recovering from Anaesthesia Related to Day

Surgery'.

Maintenance of buildings, facilities and equipment

1.2.3. ( 1 ) The buildings, facilities and equipment of a day procedure centre are to be maintained in good repair and operational order.

(2) Without limiting subclause (1), an approved maintenance programme must be current at all times for:

(a)	all air conditioning, heating, warming and cooling systems and appliances; and
(b)	all anaesthetic, endoscopic, fluoroscopic, electrosurgical and resuscitation equipment; and
( c )	all sterilising equipment; and
(d)	all fire detection and extinguishing equipment and systems; and
(e)	all communication, alarm and emergency call systems.

Security of drugs and safety of premises

1.2.4. (1) Any drug of addiction or prescribed restricted substance must be stored in a cupboard that:

(a)	is securely affixed to the premises within the clean utility area or other approved area; and
(b)	is constructed in an approved manner with approved materials; and
(c)	is fitted with a 5-lever keylock or some other locking mechanism providing at least equivalent security and
(d)	contains no other goods except drugs of addiction and prescribed restricted substances.

(2) Any other medication must be stored in a secure place in the clean utility area or in some other approved area.

(3) The day procedure centre is to be protected by means of an adequate security

system.

PART 3 - CLINICAL STANDARDS

Medical advisory committee

1.3.1. (1) A medical advisory committee (consisting of at least 5 persons who are each either medical practitioners or dentists) is to be elected, in accordance with approved guidelines, for each day procedure centre.

(2) The medical advisory committee is to be responsible for:

(a) advising the licensee on the accreditation of practitioners to provide services at the day procedure centre and on the delineation of their clinical privileges; and

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(b)	advising the licensee on matters concerning clinical practice at the day procedure centre; and
(c)	advising the licensee on matters concerning patient care and safety at the day procedure centre.

(3) The medical advisory committee is to have power to co-opt other health care providers, who may include nominees or representatives of learned colleges or other relevant professional organisations.

(4) It is a function of the medical advisory committee to report to the Director-General any persistent failure by the licensee of the day procedure centre to act on the committee’s advice.

Medical procedures

1.3.2. (1 ) Each procedure performed at the day procedure centre is to be performed by an appropriately accredited practitioner.

(2) Where a procedure involves the administration of a general, spinal, epidural, major field block or large field infiltration anaesthetic or intravenous sedative, the patient is to be attended throughout the procedure by a second appropriately accredited practitioner.

(3) A practitioner is to be responsible for selecting patients suitable for treatment by the practitioner at the day procedure centre, subject to:

(a)	the class or classes of the day procedure centre and the limitations (if any) on the services that may be provided there; and
(b)	the clinical privileges of the practitioner; and
(c)	the maintenance of high professional standards.

Quality assurance

1.3.3. ( 1 ) The licensee is to cause procedures to be established for evaluating the quality of clinical service and care provided at the day procedure centre and for correcting identified problems.

(2) Such procedures are to take account of relevant external standards and programmes recommended by learned colleges and other relevant professional organisations.

Experimental treatment

1.3.4. ( 1 ) Experimental treatment must not be carried out otherwise than in accordance with the Statement on Human Experimentation issued by the National Health and Medical Research Council.

(2) The licensee must refer any proposed new or experimental treatment to an institutional ethics committee, constituted in accordance with that Statement, and the treatment must not be carried out otherwise than in accordance with the recommendations of the committee.

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PART 4 - STAFFING

Staffing

1.4.1. (1) The nursing staff of a day procedure centre are to be sufficient in number, and are to have appropriate experience, to fully perform the nursing duties necessary for the proper care of patients at all times.

(2) If a child is admitted to a day procedure centre and the child's general state, the condition from which the child is suffering or the proposed investigation or treatment requires special paediatric facilities or services, the nursing staff on duty while the child is admitted must, unless otherwise approved, include a registered nurse with post-basic or post-graduate paediatric experience.

(3) Staff are to be provided to assist an anaesthetist in accordance with the recommendations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "Minimum Assistance Required for the Safe Conduct of Anaesthesia".

(4) The chief nurse is to cause a register to be kept in which are recorded the following particulars:

(a)

the name of each person employed in nursing duties at the day procedure

cent re;

(b)

the residential address of each such person;

(c)

in respect of each such person who is a registered or enrolled nurse:

(i)	the registration or enrolment number shown on the person's registration or enrolment certificate;
(ii)	the number and expiry date shown on the person's current annual practising certificate;
(iii)	a statement that the registration or enrolment certificate and current annual practising certificate have been seen by the chief nurse.

PART 5 - OPERATIONAL MATTERS

Pathology and radiography services

1.5.1. A surgical class day procedure centre must have access to basic pathology and radiography services within a period of time appropriate to clinical need.

Child patients

1.5.2. (1) A child is not to be admitted to a day procedure centre as a patient

unless:

(a) the day procedure centre is approved to admit child patients and the licence is endorsed accordingly; or

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(b) the admission is otherwise approved.

(2) The licensee of a day procedure centre who applies for endorsement of the licence in respect of the day procedure centre for the purposes of this clause must indicate:

(a) the age range of children to be admitted; and

(b) the types of investigation and treatment to be performed on children; and

(c) the facilities to be provided for the treatment and care of children,

for consideration in determining the conditions (if any) to be endorsed on the
licence.

(3) If a child whose age, general state, condition from which the child is suffering or proposed investigation or treatment requires special paediatric facilities or services, the day procedure centre admitting the child

(a)	must arrange for a paediatric physician to be readily available for consultation at all times; and
(b)	must ensure that any anaesthetic is administered by a specialist anaesthetist experienced in paediatric anaesthesia; and
(c)	unless otherwise approved - must have a registered nurse with post-basic or post-graduate paediatric experience on duty at all times while the child is a patient in the day procedure centre; and
(d)	must arrange for microchemistry to be readily available for analysis of capillary blood specimens from the child.

(4) If a child is admitted to a day procedure centre:

(a)	the parents of the child must have easy access to the child at all times except while the child is undergoing surgery, and
(b)	if the child is undergoing surgery, the parents of the child must have easy access to the child in the pre-anaesthetic and recovery areas unless, in the opinion of the attending practitioner, the presence of the parents in those areas is detrimental to patient welfare.

Admission and separation of patients

1.5.3. ( 1 ) On the admission of a patient to a day procedure centre:

(a)

a record of the patient’s personal particulars and reason for admission must be made; and

(b)

the patient or a person responsible for the patient must be informed in writing of:

(i)	the policy of the licensee in respect of the conduct of the day procedure centre, including charging for services, smoking by patients and staff and the handling of complaints about the day procedure centre; and
(ii)	the procedure for lodging a complaint.

(2) On the discharge of a patient from a day procedure centre, a record of further personal and clinical particulars is to be made in relation to the patient.

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(3) The records referred to in this clause are to be made:

(a)	in the register of patients; and
(b)	in the admission form for the patient concerned; and
(c)	in the morbidity form for the patient concerned.

(4) On completion of the admission details, and again on completion of the separation details, the records are to be signed by the senior nurse on duty (or by some other person authorised by the chief nurse for that purpose) and are to be dealt with as follows:

(a)	the register of patients form is to be retained in a loose-leaf file with all other completed register of patients forms;
(b)	the admission form is to be retained as the front sheet of the patient’s clinical record;
(c)	the morbidity form is, unless otherwise approved, to be submitted to the Health Statistics Unit of the Department of Health within 6 weeks after the discharge of the person to whom the record relates.

(5) A patient is not to be discharged from a day procedure centre until the patient has recovered sufficiently to no longer require regular nursing observation.

(6) A patient who has undergone general anaesthesia or intravenous sedation is not to be discharged from a day procedure centre unless accompanied by a responsible adult.

Patient cleanliness and comfort

1.5.4. (1) All practicable measures (including the prompt removal and replacement of soiled clothing and linen) must be taken to keep each patient clean and comfortable at all times.

(2) Heating and cooling facilities are to be used as necessary to maintain the comfort of each patient.

Identification of patients

1.5.5. A patient who is to undergo general anaesthesia or intravenous sedation is to have fitted around a wrist or ankle an identification band on which is indelibly and legibly written the patient’s name.

Hygiene

1.5.6. (1) Adequate facilities, equipment and stores are to be maintained for the effective cleaning and disinfection of the buildings and their fixtures and fittings.

(2) Buildings, together with their fixtures and fittings, are to be maintained in a clean and sanitary condition.

(3) Receptacles with close-fitting lids are to be provided for the collection of household refuse.

(4) Household refuse is to be disposed of by the use of a service provided by the local authority or in some other approved manner.

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(5 ) Contaminated waste is to be disposed of in an approved manner.

Smoking

1.5.7. (1) There must be a written policy on smoking in the day procedure centre by patients and staff.

(2) The policy on smoking must provide that, if patients or staff are allowed to smoke within the day procedure centre, smoking is to be confined to designated areas that allow other patients to avoid exposure to smoke without unduly restricting their activities.

Fire safety

1.5.8. (1) The licensee of a day procedure centre must have an emergency

procedures policy (including contingency arrangements for the transfer of patients
where necessary) and must ensure that all staff are familiar with the procedures.

(2) The licensee of a day procedure centre must appoint a member of the staff to be the fire safety officer for the day procedure centre and must ensure that the fire safety officer is provided with appropriate training.

(3) Each means of escape from a day procedure centre is to be kept clear of obstacles at all times.

(4) Doors and other required fire exits are to be kept in good working order and are at all times to be capable of being opened from the inside by a single-handed action.

(5) Fire detection and extinguishing equipment and systems in a day procedure centre are to be kept in good order and are to be serviced annually.

(6 ) Approved fire safety notices are to be displayed in each nurse station and in other conspicuous positions and are to be maintained in legible condition.

(7) All of the staff of a day procedure centre are to attend approved fire safety training at least once every year.

(8) A record of each such fire safety training, showing the name of each person attending and signed by the training officer, is to be maintained.

(9) All of the staff of a clay procedure centre are to participate in an evacuation exercise at least once every 6 months.

(10) If a fire occurs in a day procedure centre, the licensee, as soon as practicable after the fire and regardless of whether or not the fire brigade has been called to extinguish the fire:

must notify a nursing supervisor verbally of the fact; and

(a)

(b) must send to the Director-General written notice of the fact and of all relevant details of the circumstances in which the fire occurred.

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PART 6 - CLINICAL RECORDS

Clinical records

1.6.1. (1) A record of the medical condition of each patient in a day procedure centre, and of all medical, nursing and other care provided to each such patient, is to be maintained by an entry in a patient clinical record system made by the appropriate medical, nursing or other health care provider.

(2) Without limiting subclause (1), a patient’s clinical record must include the following:

(a)	the patient’s admission form;
(b)	the patient’s medical history, and the results of any physical examination, that may be contained in any referral document;
(c)	any medical consultation reports;
(d)	a record of any medication administered;
(e)	a record of allergies and other factors requiring special consideration;
(f)	reports of all laboratory tests performed;
(g)	reports of all X-ray and other medical imaging examinations performed;
(h)	consent or request forms, where applicable;

(i)      if a surgical procedure has been performed:

(i)	the anaesthetic record, which must comply with the recommendations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in its publication "The Anaesthetic Record";
(ii)	the operative report, including pre-operative and post-operative diagnosis, description of findings, technique used and tissue removed or altered;
(iii)	if tissue or body fluid was removed, a pathological report;
(iv)	a record of the swab, sponge and instrument count;
(v)	the post-operative recovery record;

(j)

a discharge statement, completed by the medical practitioner or dentist attending the patient, that gives the main procedures performed, the final diagnosis, the patient’s condition and recommendations and arrangements for the patient’s future care.

(3) A discharge statement referred to in subclause (2) (j) must be completed prior to the patient’s discharge unless verbal discharge instructions are given, in which case the statement must be completed within 48 hours after the patient’s discharge.

Retention of records

1.6.2. ( 1 ) The register of patients, together with the patient’s clinical records, are to be retained as follows:

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(a)	the register of patients must be kept indefinitely;
(b)	clinical records relating to patients aged 18 years or over at the date of last separation must be kept for at least 7 years from the date of last separation;
(c)	clinical records relating to patients aged under 18 years at the date of last separation must be kept until the patient to whom the record relates attains, or would have attained, the age of 25 years.

(2) If the licence of a day procedure centre is transferred to another person, the transferee is to continue to retain the register of patients and patients’ clinical records in accordance with this clause.

(3) If the licence of a day procedure centre is surrendered or cancelled, the licensee is to deal with the register and records in accordance with the instructions of the Director-General.

Patient access to clinical records

1.6.3. (1) A patient or the patient’s representative may, by written application to the licensee, request access to the patient’s clinical record.

(2) Except as provided by subclause (3), the licensee of a day procedure centre must, as soon as practicable after receipt of such an application, make the clinical record available for inspection:

(a)	by the patient or by the patient’s representative; or
(b)	by a person nominated by the patient or representative and approved by the licensee.

(3) The licensee of a day procedure centre may refuse a request by a patient or by the patient’s representative for access to the patient’s clinical record

(a)	if the medical practitioner in charge of the patient’s care advises that the request should be refused; and
(b)	if the licensee is satisfied that access by the patient or representative would be prejudicial to the patient’s physical or mental health.

(4) An application under this clause is to be retained in the patient’s clinical

record.

(5) If the licensee of a day procedure centre refuses a request by a patient or by

the patient’s representative for access to the patient’s clinical record, the licensee:

(a)	must inform the patient or representative of the reason for the refusal; and
(b)	must include in the patient’s clinical record a written note of the refusal and the reason given for the refusal.

(6) If the licensee of a day procedure centre makes clinical records available for inspection under this clause, the patient or the patient’s representative is (on payment of a fee, not exceeding the approved maximum fee, determined by the licensee) to be given assistance in the interpretation of test results, findings and comments by a person qualified to do so.

(7) If a patient or the patient’s representative disagrees with information
contained in the patient’s clinical record, the licensee must, on request by the patient

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or representative, attach the patient’s or representative’s own comments in the form
of an addendum to the record.

(8) If a patient or the patient’s representative requests particular clinical information (such as test results or details of past treatment) rather than access to the patient’s clinical record, the information may be provided by the medical practitioner in charge of the patient’s care or (subject to the advice of that medical practitioner) by a medical practitioner or registered nurse on the staff of the day procedure centre.

(9) A patient or the patient’s representative may appeal in writing to the Director-General against a decision of the licensee of a day procedure centre to refuse access to the patient’s clinical record.

(10) The Director-General may, in determining such an appeal:

(a)	confirm the decision of the licensee; or
(b)	direct that the licensee grant the patient or the patient’s representative access to the patient’s clinical record under such conditions as the Director-General may direct.

(11) A determination made by the Director-General is to be conveyed in writing

to the licensee and retained in the clinical record of the patient to whom it relates.

Confidentiality of records

1.6.4. (1 ) The licensee of a day procedure centre must ensure that, except as provided by this clause, personal information concerning a patient is not released from the day procedure centre without the consent of the patient or the patient’s representative.

(2) Personal information concerning a patient may be released from a day procedure centre without consent:

(a)	if the release of that information is required or authorised by law - in the manner so required or authorised; or
(b)	if the day procedure centre is a defendant in a case involving the patient and the release of that information is required for the defence - to the legal representative of the licensee of the day procedure centre; or
(c)	to the medical practitioner in charge of the patient’s care and, where applicable, the patient’s anaesthetist and any medical practitioner or dentist consulted on the patient’s care; or
(d)	if the patient is transferred to another health establishment - to that health establishment; or
(e)	if the patient is discharged into the care of a medical practitioner - to that medical practitioner; or
(f)	if the information is limited to a general statement about the patient’s condition and if the patient has not instructed otherwise - to a relative or friend of the patient.

(3) Access to personal information concerning a patient may be granted for bona fide research purposes without consent:

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(a)	if a comprehensive code detailing the aims, methods and reasons for the study has been approved by an institutional ethics committee referred to in clause 1.3.4; and
(b)	if the person carrying out the research does not remove the records concerned from the day procedure centre; and
(c)	if the information recorded by the person carrying out the research does not identify the patient directly, and
(d)	if the patient is not contacted directly by the person carrying out the research.

(4) Nothing in subclause (2) or (3) permits the release of personal information concerning a patient where the information consists of a confidential communication between the patient and a medical practitioner.

(5 ) All clinical records must be stored in a secure place to which unauthorised persons are not to be permitted to have access.

1990 - NO. 434

SCHEDULE 2 - FORMS

Form 1

(Cl. 6)

APPLICATION FOR LICENCE

FOR A DAY PROCEDURE CENTRE

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ..................................................................................................................

(full name of applicant[s])

of ..........................................................................................................................

(address of applicant[s])

hereby apply for a licence for a day procedure centre of the following class[es]

..............................................................................................................................

The day procedure centre will be known as

..............................................................................................................................

(proposed name)

and will be situated at

...............................................................................................................................

(proposed location)

The applicant[s] is/are/will be

* owner[s] * lessee[s]

of the day procedure centre.

I/We attach hereto the following information:

(1)

In the case of an application by a corporation:

(a)	a copy of the certificate of incorporation;
(b)	the address of the registered office of the corporation;
(c)	the full name, residential address and position of:

(i)           each current director of the corporation;

(ii)          the principal executive officer of the corporation;

(iii)         the secretary or, if there is more than one, each secretary of the corporation;

1990 - NO. 434

(d)

in the case of a corporation limited by shares:

(i)	the types of shares and the number of shares of each type issued;
(ii)	in the case of a private corporation - the full name of, and the number of shares of each type held by, each shareholder;
(iii)	in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;

(e)

if the shares are held by another corporation, the name of the ultimate holding corporation.

(2)	If the day procedure centre is leased, a copy of the lease.
(3)	If the day procedure centre is proposed to be leased, a description of the proposed lease arrangements.

I/We also forward herewith the prescribed application fee.

…………………………… ……………………………

(Print name) (Signature)

…………………………… ……………………………

(Position) (Date)

* Delete whichever is not applicable

1990 - NO. 434

Form 2

(Cl. 9)

APPLICATION FOR TRANSFER OF LICENCE

FOR A DAY PROCEDURE CENTRE

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ....................................................................................................................

(full name of applicant[s])

of ....................................................................................................................

(address of applicant[s])

hereby apply for a transfer to me/us of the licence for the day procedure centre known

as ..................................................................................................................

(name of day procedure centre)

at .....................................................................................................................

(address of day procedure centre)

The applicant[s] is/are/will be

* owner[s] * lessee[s]

of the day procedure centre.

I/We attach hereto the following information:

(1 )

In the case of an application by a corporation:

(a)	a copy of the certificate of incorporation;
(b)	the address of the registered office of the corporation;
(c)	the full name, residential address and position of:

(i)           each current director of the corporation;

(ii)          the principal executive officer of the corporation;

(iii)         the secretary or, if there is more than one, each secretary of the corporation;

(d)

in the case of a corporation limited by shares:

(i)	the types of shares and the number of shares of each type issued;
(ii)	in the case of a private corporation - the full name of, and the number of shares of each type held by, each shareholder;
(iii)	in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;

1990 - NO. 434

(e) if the shares are held by another corporation, the name of the ultimate holding corporation.

(2)	If the day procedure centre is leased, a copy of the lease.
(3)	If the day procedure centre is proposed to be leased, a description of the proposed lease arrangements.

I/We also forward herewith the prescribed application fee.

…………………………… ………………………………

(Print name) (Signa tu re)

…………………………… ………………………………

(Position) (Date)

TO BE COMPLETED BY CURRENT LICENSEE

I/We agree to the transfer of the licence to the abovenamed applicant(s).

…………………………… ……………………………

(Print name) (Signature)

…………………………… ……………………………

(Position) (Date)

* Delete whichever is not applicable

1990 - No. 434

Form 3

(Cl. 10)

APPLICATION FOR APPROVAL TO ALTER OR EXTEND

A LICENSED DAY PROCEDURE CENTRE

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ................................................................................................................................

(name of licensee)

of ......................................................................................................................................

(address of licensee)

being the holder of the licence (No. ..............) for the day procedure centre known

as .......................................................................................................................................

(name of day procedure centre)

at ................................................................................................................................

(address of day procedure centre)

hereby apply for approval to alter or extend the day procedure centre.

I/We attach hereto the following documents:

(1)	Two copies of a site plan of the day procedure centre, drawn to scale and showing the lot number and deposited plan number or other relevant particulars which identify the site.
(2)	Two copies of sketch plans of the day procedure centre, drawn to a scale of
1:100 and showing the dimensions of each part of the day procedure centre and the use to which each part is to be put (the proposed alterations or extensions to the day procedure centre are shown by distinctive colouring or
cross- hatching).
……………………………	……………………………

(Print name) (Signature)

…………………………… ……………………………

(Position) (Date)

1990 - NO. 434

Form 4

(Cl. 11)

APPLICATION FOR REVIEW

OF DIRECTOR-GENERAL’S DECISION

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ....................................................................................................................................

(name of applicant)

of ...........................................................................................................................................

(address of applicant)

hereby apply for a review of the decision of the Director-General to:

.............................................................................................................................................

(nature of decision)

I/We enclose a copy of the Director-General’s letter notifying the decision.

The grounds for my/our request for review are as follows:

...................................................................................................................................................

...................................................................................................................................................
...................................................................................................................................................

I/We understand that this application will be referred to a Committee of Review, which may make such investigation as it considers necessary in relation to this application before reporting to you. I/We agree, for this purpose, to allow any member of the Committee access to documentation, staff and patients, as judged necessary by the Committee. I/We also agree to relevant documentation held by the Department of Health being made available to members of the Committee for the purposes of its investigation.

.................................................. ...................................................

(Print name) (Signature)

.................................................. ....................................................

(Position) (Date)

1990 - No. 434

Form 5

(Cl. 12)

NOTIFICATION OF PARTICULARS OF PERSON

TO BE APPOINTED AS CHIEF NURSE OF A DAY PROCEDURE CENTRE

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, .....................................................................................................................................

(name of licensee)

of ...........................................................................................................................................

(address of licensee)

hereby notify the Director-General that

.........................................................................................................................................

(name of appointee)

of ..............................................................................................................................................

(residential address of appointee)

who is registered as a ..........................................................................................................

(nature of registered qualification)

registered number ...............................................................................................................

(number of registration certificate issued

by the Nurses Registration Board of N.S.W.)

with ................................ years of post-basic or post-graduate nursing experience

(number of years)

has been appointed to carry out the duties of chief nurse at

.............................................................................................................................................

(name of day procedure centre)

of .............................................................................................................................................

(address of day procedure centre)

from ........................................................................................................................................

(date of commencement of duty)

I attach hereto:

(1)	The appointee’s curriculum vitae.
(2)	A copy of the appointee’s current annual practising certificate.

1990 - NO. 434

.................................................. ...................................................

(Print name) (Signature)

.................................................. ....................................................

(Position) (Date)

....................................................

(Signature of appointee)

1990 - NO. 434

Form 6

(Cl. 13)

REGISTER OF PATIENTS AT A DAY PROCEDURE CENTRE

(Private Hospitals and Day Procedure Centres Act 1988)

1990 - No. 434

Form 7

(Cl. 14)

DAY PROCEDURE CENTRE ADMISSION FORM

(Private Hospitals and Day Procedure Centres Act 1988)

1990 - No. 434

Form 8

(Cl. 14)

DAY PROCEDURE CENTRE MORBIDITY FORM

(Private Hospitals and Day Procedure Centres Act 1988)

1990 - NO. 434

Form 9

(Cl. 17)

LICENSEE’S ANNUAL CERTIFICATE

FOR A DAY PROCEDURE CENTRE

(Private Hospitals and Day Procedure Centres Act 1988)

Name of licensee: ....................................................................................................................

Address of licensee: ...............................................................................................................

Name of day procedure centre: ...........................................................................................

Address of day procedure centre: .......................................................................................

Class(es) of day procedure centre: .....................................................................................

Name of chief nurse: ...........................................................................................................

Registration No. of chief nurse: ........................................................................................

The day procedure centre is

* owned by the licensee

* leased from .................................................................................................................

(name of lessor)

I/We forward herewith:

(1) The prescribed annual licence fee.

(2)	A copy of the chief nurse’s current annual practising certificate.
(3)	If the licensee is a corporation: (a) the full name of the corporation;
(b) the address of the registered office of the corporation;

1990 - NO. 434

(c)

the full name, residential address and position of:

(i)	each current director of the corporation;
(ii)	the principal executive officer of the corporation;
(iii)	the secretary or, if there is more than one, each secretary of the corporation;

(d)

in the case of a corporation limited by shares:

(i)	the types of shares and the number of shares of each type issued;
(ii)	in the case of a private corporation - the full name of, and the number of shares of each type held by, each shareholder;
(iii)	in the case of a public corporation - a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings;

(e)

if the shares are held by another corporation, the name of the ultimate holding corporation.

.................................................. ...................................................

(Print name) (Signature)

.................................................. ....................................................

(Position) (Date)

* Delete whichever is not applicable

1990 - NO. 434

FORM 10

(Cl. 18)

DAY PROCEDURE CENTRE STATISTICAL STATEMENT

(Private Hospitals and Day Procedure Centres Act 1988)

DAY PROCEDURE CENTRE ...........................................................................

CODE No: ................

STATEMENT FOR MONTH OF ....................................... 19 .........

ALL PATIENTS ADMITTED DURING MONTH

Private patients	.....................
Nursing home type patients	.....................
Compensable and ineligible patients	.....................
Total patients	.....................

1990 - NO. 434

NOTE

TABLE OF PROVISIONS

PART 1 - PRELIMINARY

1. Citation
2. Commencement
3. Application

4. Definitions

PART 2 - LICENSING OF DAY PROCEDURE CENTRES

5. Licensing standards
6. Applications for licences

7.     Classes of day procedure centres

8. Annual licence fees 9. Transfer of licence

10.    Alterations or extensions

11.     Application for review of Director-General’s decision

12. Chief nurse
13. Register of patients

14. Records

PART 3 - MISCELLANEOUS

15. Evidentiary certificates
16. Display of licence

17.     Information to be furnished with annual licence fee

18. Information to be furnished periodically

SCHEDULE 1 - LICENSING STANDARDS

SCHEDULE 2 - FORMS

EXPLANATORY NOTE

The objects of this Regulation are to make provisions necessary or convenient for carrying out or giving effect to the Private Hospitals and Day Procedure Centres Act 1958 in so far as that Act applies to Day Procedure Centres. Apart from machinery provisions, the Regulation deals primarily with licensing standards. These standards include provisions concerning design and construction of premises, facilities and equipment, clinical standards, staffing, operational matters and clinical records.