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B.C. Reg. 121/97
O.C. 414/97
Deposited April 3, 1997
effective April 15, 1997
This consolidation is current to November 14, 2017.
Link to Point in Time

Hospital Act

Hospital Act Regulation

[includes amendments up to B.C. Reg. 225/2016, September 20, 2016]

Contents
1Definitions
2Prescribed health professions
3Administrator of a hospital
4Medical staff of a hospital
5Bylaws respecting health care responsibilities
6Board's power to exclude from the hospital
7Attending and treating patients in a hospital
8Applications for permits to practise in a hospital
9Repealed
10Repealed
11Admission to hospital of patients
11.1Patient records if treatment or services provided
12Discharge from hospital of patients
13Documents comprising health records
14Destruction of health record documents
15Hospital records and investigation of practitioners
16X-rays
17Accounting
18Abortion services
19Suspension of private hospital operations
20Priority placement programs for hospital employees
21Duty to report adverse events
Schedule

Definitions

1  In this regulation:

"Act" means the Hospital Act;

"administrator" means the chief administrative officer of a hospital, designated by the hospital's board under section 3;

"board" means board of management as defined in section 1 of the Act;

"hospital" means, except in section 19 of this regulation, an institution designated as a hospital under section 1 of the Act;

"Hospital Appeal Board" means the Hospital Appeal Board continued under section 46 of the Act.

[am. B.C. Regs. 45/2004, s. (b) (i); 206/2013, s. 1.]

Prescribed health professions

2  For the purpose of the definition of "practitioner" in section 1 of the Act, the following are prescribed health professions:

(a) dentistry;

(a.1) medicine;

(b) midwifery;

(c) nursing, if practised by a nurse practitioner.

[en. B.C. Reg. 421/2008, App. s. 7 (a); am. B.C. Regs. 423/2008, App. s. 7 (a); 279/2012, Sch. 1, s. 1.]

Administrator of a hospital

3  (1) A board must designate one person as the administrator, who

(a) is the board's representative, and

(b) is vested with, to the extent authorized by the board, the power to exercise the functions of the board at times when it is inconvenient to call a meeting of the board.

(2) An administrator must

(a) attend all meetings of

(i) the hospital's medical staff, and

(ii) the hospital's board,

and act as the liaison between these bodies, and

(b) execute all orders of the hospital's board concerning the administration of the hospital.

(3) The decision of an administrator prevails on a question concerning hospital administration unless that decision is cancelled or overturned by the hospital's board.

Medical staff of a hospital

4  (1) A hospital's board must organize a medical staff of which every practitioner regularly practising in the hospital must be a member.

(2) A hospital's board must, after consultation with the executive body of the hospital's medical staff, promulgate bylaws for that medical staff.

(3) A hospital's medical staff must comply with all of the following:

(a) meet regularly in accordance with the Standards issued by the Canadian Council on Health Agency Accreditation;

(b) keep proper minutes of its meetings;

(c) act in an advisory capacity to the hospital's board, in the manner provided in this regulation and provided in the bylaws and rules, if any, of the hospital;

(d) make recommendations regarding the various categories of medical staff membership to be established by the hospital's board and the duties, responsibilities and privileges to be assigned to each category;

(e) assist the hospital's board in providing adequate documentation for the purpose of maintaining a health record for each patient;

(f) participate in appropriate quality improvement activities, including, without limitation, reviewing the following:

(i) deaths occurring in the hospital;

(ii) statistics regarding the progress of patients in the hospital;

(iii) methods of treatment of patients in the hospital;

(iv) results of surgery performed in the hospital;

(v) a case when a patient's stay in the hospital is abnormally long;

(g) report to the hospital's board the name of any member who, without reasonable excuse, fails to attend its meetings or to participate in the performance of its duties;

(h) discipline any of its members in a manner it thinks fit and, if the circumstances in any case so warrant, recommend to the hospital's board the cancellation, suspension, restriction or non-renewal of the member's permit to practise in the hospital.

Bylaws respecting health care responsibilities

5  A hospital's board must provide in the bylaws of its medical staff a procedure under which

(a) the responsibility for medical care of a patient who is admitted by a medical practitioner

(i) is assumed, throughout the patient's stay in the hospital, by an attending medical practitioner on the medical staff, and

(ii) may be transferred

(A) from one medical practitioner on the medical staff to another, or

(B) when necessary and appropriate, to a midwife or nurse practitioner on the medical staff,

(b) the responsibility for dental care of a patient

(i) is assumed, throughout the patient's stay in the hospital, by an attending dentist on the medical staff, and

(ii) may be transferred from one dentist on the medical staff to another,

(c) the responsibility for midwifery care of a patient who is admitted by a midwife

(i) is assumed, throughout the patient's stay in the hospital, by an attending midwife on the medical staff, and

(ii) may be transferred

(A) from one midwife on the medical staff to another,

(B) when necessary, to a medical practitioner on the medical staff, or

(C) when necessary and appropriate, to a nurse practitioner on the medical staff, and

(d) the responsibility for nurse practitioner care of a patient who is admitted by a nurse practitioner

(i) is assumed, throughout the patient's stay in the hospital, by an attending nurse practitioner on the medical staff, and

(ii) may be transferred

(A) from one nurse practitioner on the medical staff to another,

(B) when necessary, to a medical practitioner on the medical staff, or

(C) when necessary and appropriate, to a midwife on the medical staff.

[en. B.C. Reg. 279/2012, Sch. 1, s. 2.]

Board's power to exclude from the hospital

6  A hospital's board may exclude a person from the hospital and prohibit that person from attending, treating or rendering health care services to patients in the hospital, if the person refuses or neglects to comply with any provision of the following after due notice in writing:

(a) the Act;

(b) this regulation;

(c) the hospital's medical staff bylaws;

(d) any other Act that pertains to the hospital and the members of its medical staff.

Attending and treating patients in a hospital

7  (1) A practitioner is not entitled to attend or treat patients in a hospital or in any way make use of the hospital's facilities for his or her practice unless the practitioner

(a) is a person who is authorized to practise a profession regulated by one or more of the following:

(i) the College of Physicians and Surgeons of British Columbia;

(ii) the College of Dental Surgeons of British Columbia;

(iii) the College of Midwives of British Columbia;

(iv) the College of Registered Nurses of British Columbia, and

(b) holds a valid permit, issued by the hospital's board, to practise in the hospital.

(2) A permit issued under subsection (1) (b) does not entitle a practitioner to patient admitting and discharging privileges in the hospital unless the practitioner to whom the permit is issued

(a) is a medical practitioner,

(b) for the purpose of dentistry, is an oral and maxillofacial surgeon,

(c) for the purpose of midwifery, is a midwife, or

(d) for the purpose of nursing, is a nurse practitioner.

(3) Nothing in subsection (1) or (2) prohibits a hospital from providing a person with diagnostic or treatment services on an out-patient basis at the written request of a duly qualified practitioner who does not hold a permit to practise in the hospital.

(4) If a person is not a member or registrant of a college referred to in subsection (1) but is a member of a legally established medical, dental, midwifery or nursing body that governs the practice of medicine, dentistry, midwifery or nursing, as the case may be, in a jurisdiction other than British Columbia, a hospital's board may issue to that person a special permit so that the person may attend or treat patients for the purpose of providing educational services or necessary health care services, but that person must be registered for this purpose with

(a) the College of Physicians and Surgeons of British Columbia,

(b) the College of Dental Surgeons of British Columbia,

(c) the College of Midwives of British Columbia, or

(d) the College of Registered Nurses of British Columbia.

(5) A special permit issued by a hospital's board under subsection (4) does not entitle the person to whom it is issued to patient admitting and discharging privileges in the hospital.

(6) If a hospital's board cancels, suspends for more than one month, places a restriction on or refuses to issue or renew a permit referred to in subsection (1) or (4), the board must, within 7 days of that action, give notice of that action to

(a) if the affected individual is registered with the College of Physicians and Surgeons of British Columbia, the College of Physicians and Surgeons of British Columbia,

(b) if the affected individual is registered with the College of Dental Surgeons of British Columbia, the College of Dental Surgeons of British Columbia,

(c) if the affected individual is registered with the College of Midwives of British Columbia, the College of Midwives of British Columbia, and

(d) if the affected individual is registered with the College of Registered Nurses of British Columbia, the College of Registered Nurses of British Columbia.

(7) Despite subsection (1), a hospital's board may provide in the bylaws, or in the rules governing the organization and management of the hospital's medical staff, for the rendering of health care services to a patient by a person who is not a member of a college referred to in subsection (1), if those bylaws or rules ensure that all of the following conditions are met:

(a) in the case of a patient who is admitted by a medical practitioner, the responsibility for

(i) discharging the patient from the hospital, and

(ii) the medical care of the patient while in the hospital

rests with the medical practitioner on the hospital's medical staff who is attending the patient;

(b) in the case of a patient who is admitted by an oral and maxillofacial surgeon, the responsibility for

(i) discharging the patient from the hospital, and

(ii) the dental care of the patient while in the hospital

rests with the oral and maxillofacial surgeon on the hospital's medical staff who is attending the patient;

(c) the responsibility for the dental care of a patient while in the hospital rests with the dentist on the hospital's medical staff who is attending the patient;

(d) in the case of a patient who is admitted by a midwife, the responsibility for

(i) discharging the patient from the hospital, and

(ii) the midwifery care of the patient while in the hospital

rests with the midwife on the hospital's medical staff who is attending the patient;

(e) in the case of a patient who is admitted by a nurse practitioner, the responsibility for

(i) discharging the patient from the hospital, and

(ii) the nurse practitioner care of the patient while in the hospital

rests with the nurse practitioner on the hospital's medical staff who is attending the patient.

[am. B.C. Reg. 279/2012, Sch. 1, s. 3.]

Applications for permits to practise in a hospital

8  (1) An application by a duly qualified medical practitioner, dentist, midwife or nurse practitioner for a permit to practise medicine, dentistry, midwifery or nursing as a nurse practitioner in a hospital, or for the renewal of the permit, must be made in writing to the administrator of the hospital.

(2) The administrator must

(a) promptly direct the application referred to in subsection (1) to the credentials committee or other appropriate body of the medical staff, and

(b) report the receipt of the application to the hospital's board at its next meeting.

(3) Within 60 days after the date that the credentials committee or other appropriate body receives an application under subsection (2), it must consider the application and report in writing its recommendations regarding the application to the medical advisory committee or other executive body of the medical staff, and that respective medical advisory committee or executive body must

(a) consider the application and the report of the credentials committee or other appropriate body, and

(b) notify the hospital's board in writing of its recommendations regarding the application.

(4) The hospital's board must review the application referred to in subsection (1), consider the recommendations made to it under subsection (3), make a decision on the application and, within 120 days after the administrator's receipt of the application under subsection (1), give notice in writing of the board's decision

(a) to the applicant, and

(b) to the hospital's medical staff.

(5) A duly qualified practitioner

(a) who has filed an application under this section and who has not been notified by the hospital's board within the time prescribed under this section,

(b) whose application under this section has been refused in whole or in part, or

(c) whose permit to practise in a hospital has been cancelled, suspended, restricted or not renewed

is entitled, on application in writing to the hospital's board, to appear in person or by counsel and make representations to the board, and the board must hear and consider, or reconsider as the case may be, the matter and advise the applicant in writing of its decision by registered mail within 30 days after the date that the applicant or the applicant's counsel appeared before the board.

(6) to (8) Repealed. [B.C. Reg. 516/2004, s. (c) (ii).]

[am. B.C. Regs. 516/2004, s. (c) (ii); 279/2012, Sch. 1, s. 4.]

Repealed

9  Repealed. [B.C. Reg. 45/2004, s. (b) (ii).]

Repealed

10  Repealed. [B.C. Reg. 516/2004, s. (c) (iii).]

Admission to hospital of patients

11  (1) A person must not be admitted to a hospital as a patient except by an order of the hospital's board or of a person authorized by that board for this purpose.

(2) When a patient is admitted to a hospital or as soon as practicable after that time, the attending practitioner or practitioners, as the case may be, must report to the board a preliminary diagnosis of the disease or condition for which the patient is receiving health care services.

Patient records if treatment or services provided

11.1  A hospital must keep, as part of a patient's health record, records supplied to the hospital by any person that are relevant to

(a) the treatment of the patient, or

(b) the provision of services to the patient.

[en. B.C. Reg. 224/2016, Sch. 2.]

Discharge from hospital of patients

12  For the purpose of discharging a patient from a hospital,

(a) the patient must not be discharged except by an order of the hospital's board or of a person authorized by that board for this purpose,

(b) except in the circumstances described in paragraphs (d) and (e), the discharge order referred to in paragraph (a) may be issued only when the patient's attending practitioner or practitioners, as the case may be, gives notice to the hospital's board that the patient is fit for discharge,

(c) the hospital's board or administrator may, at any time, require the attending practitioner or practitioners, as the case may be, to submit a written statement concerning whether the patient is fit for discharge, and if the attending practitioner is of the opinion that the patient is not fit for discharge, the practitioner must provide in the written statement reasons for that opinion,

(d) if, in the opinion of the hospital's board, the written statement referred to in paragraph (c) and the health record of the patient do not show that it is necessary for the patient to remain in the hospital, the board may discharge the patient,

(e) if the patient leaves the hospital against the advice of the patient's attending practitioner, this fact must be stated on the patient's discharge order referred to in paragraph (a),

(f) any practitioner report related to discharging the patient from the hospital, including the written statement referred to in paragraph (c), must be added to the health record of the patient, and

(g) the discharging of the patient from the hospital by the hospital's board under this section is withdrawal of the privilege of further residence in the hospital and must not be considered discharge from a practitioner's care.

Documents comprising health records

13  (1) In this section and section 14:

"primary document" means a document that contains

(a) pertinent health care data of a patient's health record including case histories, discharge summaries, consultation reports, day care records and other documents prepared or signed by an attending practitioner or, as the case may be, practitioners, and

(b) reports regarding significant findings, items or comments, initially recorded in a secondary or transitory document, that have been transferred to and recorded on a primary document;

"secondary document" means a document that contains information about a patient that may be of vital medical importance at a particular time and may have lasting legal significance but is not considered necessary for care and treatment of the patient beyond that particular time, and includes any diagnostic report, authorization, out-patient record, adverse event report made under section 21 and nursing report or note;

"transitory document" means a document that appears to have no medical importance or lasting legal significance once a patient has been discharged from a hospital, and includes a diet report, graphic chart or departmental checklist.

(2) Before a patient's health record is finally completed by the patient's attending practitioner in a hospital and is placed in storage, the Health Record Administrator of the hospital, or any other employee of the hospital who is responsible for the final custody of patient health record documents, must classify each document comprising the patient's health record as either a primary document, secondary document or transitory document.

(3) Any practitioner attending a patient in a hospital must, before finally completing the patient's health record, ensure that every item or comment that the practitioner considers significant in a secondary or transitory document concerning that patient be recorded on the primary document for that patient.

(4) A patient's health record

(a) must be comprised of original documents, and

(b) may contain a copy of an original document only if it is not practicable to provide the original.

[am. B.C. Reg. 206/2013, s. 2.]

Destruction of health record documents

14  (1) A document regarding a patient who, as an in-patient or out-patient, has received a hospital's treatment or services, must be retained by the hospital for at least the following periods of time:

(a) in the case of a primary document, 10 years from the most recent day that the patient was discharged from the hospital;

(b) in the case of a secondary document, 6 years from the date that the patient was discharged from the hospital after receiving the treatment or services to which the document applies;

(c) in the case of transitory documents, one year from the date of final completion of the patient's health record by the attending practitioner or practitioners, as the case may be.

(2) A board may, by resolution, instruct and authorize its administrator to cause to be destroyed, on expiry of the respective minimum retention period under subsection (1), a health record document.

(3) Despite an instruction issued under subsection (2), the administrator may determine that some health record documents have continuing value for research, historical or other purposes and the administrator may direct that those documents be retained for a further period that is specified by the administrator and after which those documents may be destroyed.

Hospital records and investigation of practitioners

15  (1) When the conduct or fitness to practise or the competence of a medical practitioner is under investigation or is the subject of an inquiry under the Health Professions Act, the Board of the College of Physicians and Surgeons of British Columbia or its nominee is authorized to examine the records of a hospital concerning any health care services rendered to a patient by that medical practitioner or under the direction of that medical practitioner.

(2) When the conduct or fitness to practise or the competence of a dentist is under investigation or is the subject of an inquiry under the Health Professions Act, the Board of the College of Dental Surgeons of British Columbia or its nominee is authorized to examine the records of a hospital concerning any health care services rendered to a patient by that dentist or under the direction of that dentist.

(3) When the conduct or fitness to practise or the competence of a midwife is under investigation or is the subject of an inquiry under the Health Professions Act, the Board of the College of Midwives of British Columbia or its nominee is authorized to examine the records of a hospital concerning any health care services rendered to a patient by that midwife or under the direction of that midwife.

(4) When the conduct or fitness to practise or the competence of a nurse practitioner is under investigation or is the subject of an inquiry under the Health Professions Act, the Board of the College of Registered Nurses of British Columbia or its nominee is authorized to examine the records of a hospital concerning any health care services rendered to a patient by that nurse practitioner or under the direction of that nurse practitioner.

[am. B.C. Regs. 421/2008, App. s. 7 (b); 423/2009, App. s. 7 (b); 279/2012, Sch. 1, s. 5.]

X-rays

16  (1) In this section:

"practitioner" has the same meaning as in the Medicare Protection Act;

"service" means a service to which section 4.09 (1) of the Medical Service Act Regulations applies;

"X-ray" means an X-ray prepared in a hospital or supplied to a hospital by a medical practitioner but does not include an X-ray report.

(2) A board must provide a copy of a patient's X-ray to the patient or to a practitioner performing a service for the patient, if the board receives

(a) the written consent, in the form provided in the Schedule, of the patient or the legal representative of the patient, and

(b) payment of the costs of making and delivering the copy.

(3) Instead of providing a copy under subsection (2), a board may, subject to receiving the consent referred to in subsection (2) (a) and the payment of the costs of delivery, release the original X-ray to the patient or to a practitioner described in that subsection.

(4) A person who has access to a patient's X-ray under this section must use it only for the purposes of diagnosis and treatment and must not disclose to any person, other than the patient, any information obtained from the X-ray concerning the patient.

Accounting

17  A hospital must install a system of accounting and must maintain its financial and statistical records in a manner satisfactory to the minister.

Abortion services

18  Each hospital listed in Schedule A of the Hospital Insurance Act Regulations must be operated and managed in a manner that allows beneficiaries, as defined in section 1 of the Hospital Insurance Act, to receive abortions at that hospital.

[am. B.C. Reg. 225/2016, Sch. 2.]

Suspension of private hospital operations

19  Subject to section 6 of the Hospital Act, a private hospital licensed under Part 2 of the Act must not suspend its operation, whether temporarily or permanently, unless it has given 12 months written notice to the chief inspector.

Priority placement programs for hospital employees

20  (1) In this section:

"hospital" means

(a) a hospital designated under this section by the minister, or

(b) a hospital that has entered into an agreement under this section with the minister;

"hospital employee" means a person

(a) employed at a hospital but who may be laid off as the result of restructuring at the hospital, or

(b) formerly employed at a hospital who was laid off after April 30, 1992, for reasons other than cause.

(2) The minister may establish a program, or a hospital and the minister may agree to a program, for the priority placement of hospital employees in the hospital, or in another facility, in accordance with specified terms and conditions.

(3) If the minister and a hospital have been unable to reach an agreement under subsection (2), the minister may designate the hospital as subject to the requirements of a priority placement program established under subsection (2) and may

(a) exempt the designated hospital from specific requirements, or

(b) impose additional requirements on the hospital for purposes of the program.

Duty to report adverse events

21  (1) In this section:

"private hospital" means a private hospital licensed under Part 2 of the Act;

"serious adverse event" means an incident that

(a) took place in a hospital or private hospital,

(b) was the likely cause of, or likely significantly contributed to, severe harm to or the death of a patient,

(c) was not expected or intended to occur, and

(d) was not caused by or related to an underlying medical condition of the patient;

"severe harm" means any physical or psychological injury to a patient

(a) that, on a permanent or long-term basis, substantially interferes with a patient's functional abilities or quality of life, and

(b) that causes the patient to

(i) suffer pain or disfigurement,

(ii) require major medical or surgical treatment,

(iii) require emergency medical treatment to prevent death, or

(iv) have a shortened life expectancy.

(2) The following persons must report to the minister each serious adverse event:

(a) for a hospital, the administrator;

(b) for a private hospital, the licensee.

(3) A report under subsection (2) must be made

(a) immediately after the adverse event occurs, and

(b) in the form and manner specified by the minister.

[en. B.C. Reg. 206/2013, s. 3.]

Schedule

Authorization for Release of Patient Information

I, ......................................................................................, hereby authorize ...................................................................[Name of Hospital Releasing Information] to release the following information: (*Describe - see note below)
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
to me or to .....................................................................................................................................................
.......................................................................................................................................................................
[Name and Address of Person Authorized to Receive Information] from the records of .................................................................................................. [Name of Patient] born ................................................................................................... [Patient's Date of Birth]

and presently residing at ................................................................................................................................
......................................................................................................................................................................
[Address of Patient]

I consent to the use of this information by the authorized recipient only for the purposes of ......................................................................................................................................................................
......................................................................................................................................................................
I hereby release the hospital, its employees and agents from any claim that may arise as a result of the release of the above information.

I have reached the age of 19 years.
Dated ............................................................................. [Month, Day, Year]

............................................................................... [Patient's or Representative's Signature]

Please state relationship to patient: ............................................................................................

Witness:
....................................................................................... [Signature]
....................................................................................... [Name]
....................................................................................... [Address]
....................................................................................... [Occupation]
This Authorization will expire 6 months from the above date, or on ................................... [Month, Day, Year]

NOTE:

The description of information to be released should include an approximate date of the clinical record and an indication of the specific information requested from the record.

If an authorization is given other than by the patient, proof of guardianship or appointment as representative must be given.

This authorization form must be presented in duplicate to the hospital.

Information will be released only after the hospital has been paid the costs of making and delivering a copy, or, if the original record is released, the costs of delivery.

[Provisions relevant to the enactment of this regulation: Hospital Act, R.S.B.C. 1996, c. 200, section 56]