Rule 360-41-.03 - Medical Records(1) The physician performing office based surgery must maintain a legible, complete, comprehensive and accurate medical record for each patient. The medical record shall include:(a) Identity of the patient;(b) History and physical, diagnosis, and treatment plan;(c) Appropriate labs, x-rays, or other diagnostic reports;(d) Appropriate pre-anesthesia evaluation;(e) Narrative description of procedure;(f) Pathology reports if relevant;(g) Documentation of which, if any, tissues and specimens have been submitted for histopathologic diagnosis;(h) Provisions for continuity of postoperative care; and(i) Documentation of the outcome and the follow-up plan.(2) When moderate sedation/analgesia, deep sedation/analgesia, major conduction anesthesia, or general anesthesia is used, the patient's medical record shall include a separate anesthesia record which includes: (a) The type of sedation or anesthesia used;(b) Drugs (name and dose) administered and time of administration;(c) The patient's vital signs at regular intervals including, at a minimum, blood pressure, heart rate, respiratory rate and oxygen saturation; and(d) Documentation of a return to appropriate level of consciousness and readiness for discharge from acute care.Ga. Comp. R. & Regs. R. 360-41-.03
O.C.G.A. § 43-34-47.
Original Rule entitled "Medical Records" adopted. F. Apr. 26, 2023; eff. May 16, 2023.