S.L. 94.11 Art. 32Report on and history of the patient.

As soon as possible after admission and in any case within twenty-four hours of admission, the medical officer is to draw up -

(a) a complete and detailed report on the physical and psychological condition of the patient on the official case sheet;

(b) a history of the case as obtained in an interview with the relatives or friends of the patient.

Subsequently, entries describing the course and progress of the case and recording the medical and other treatment, with the results, shall be made on the clinical record as follows: during the first month after admission, twice in every week and more often when necessary; afterwards, in recent cases, once at least in every month; in other cases, notes shall be made as frequently as necessary but at least three times a year, and one of these notes shall contain the result of a complete physical examination. All entries in the clinical record must be signed by the medical officer making them.