Rule 111-8-4-.12 - Records(1) A full-time employee shall be designated responsible for establishing and maintaining medical records required to be kept by these rules and regulations.(2) Medical records containing sufficient information to validate the diagnosis and to establish the basis upon which treatment is given shall be maintained on each patient. Contents of individual medical records shall normally contain the following at least:
(a) Admission and discharge data:1. Name, address, birth date, sex, marital status, race, etc.2. Date and time of admission.3. Date and time of discharge.6. Procedures or operations performed.7. Condition on discharge.8. Attending practitioner's signature.(b) History and physical examination data: 1. Personal medical history (including all current medication that the patient is taking).2. Family medical history.4. Psychiatric examination (if applicable).(c) Treatment data:1. Practitioner's orders.5. Temperature-Pulse-Respiration (Graphic Chart; surgical purposes only).6. Special examination(s) and reports (include x-ray and lab reports).7. Signed informed consent form.9. Anesthesia record (if applicable).10. Consultation record (if applicable).11. Tissue findings when performed.12. Where dental services are rendered, a complete dental chart with dental diagnosis, treatment, prescription and progress notes shall be part of the clinical record.(3) All orders on patients shall be signed by the practitioner giving them; admitting diagnosis (purpose of admission) shall be recorded prior to or at the time of admission.(4) Medical records shall be preserved as original records, microfilms or other usable forms and shall be such as to afford a basis for complete audit of professional information. Centers shall retain all medical records, at least until the sixth anniversary of the patient's discharge. In the case of patients who have not attained majority at the time of the discharge, centers shall retain such records at least six (6) years after patient reaches age of majority. In the event a center shall cease operation, the Department shall be advised of the disposition and/or location of said records.(5) The center shall collect, retrieve and annually summarize data from the medical record so that it may provide the Department with the following medical statistical information including: (a) Number of visits by patients.(b) Number of patients seen.(c) Basis of treatment (clinical diagnosis and/or problem for which the patient was treated).(d) Types and number of operative procedures performed.(e) Age distribution of patients.(f) Complications and emergencies.(g) Number of times a patient was transferred from the center to a hospital.(h) Pathological diagnosis.(6) Patient records shall be current and shall be entitled to the same protection as provided for any medical records under Georgia law.Ga. Comp. R. & Regs. R. 111-8-4-.12
O.C.G.A. §§ 31-2-4et seq. and 31-7-1 et seq.
Original Rule entitled "Records" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.