Ga. Comp. R. & Regs. R. 111-8-22-.14 - Medical Records
(1)
A current and complete medical record shall be maintained for each
patient.
(2) The facility shall
designate a supervisor for the medical records who shall be responsible for the
organization, proper documentation, completion and preservation of the
facility's medical records.
(3) The
medical records shall be organized in a manner to facilitate the completion and
retrieval of information.
(4)
Patients' medical records for the most recent two years shall be kept on site.
The remainder of the patient's medical record may be stored off-site if the
record is readily available. Medical records shall be retained for at least
five years following the date of death or discharge. For pediatric patients,
the records shall be retained for three years after the patient reaches the age
of majority, or at least five years, whichever is longer.
(5) Medical records shall be available for
inspection only to members of the professional staff, the patient,
representatives of the Department acting in an official capacity, or persons
authorized in writing by the patient to have access to the medical record.
(a) The facility shall release copies of all
or part of a patient's medical record to an authorized representative of the
Department at no cost to the Department when the Department determines that
said records are necessary in connection with the Department's licensing and
certification responsibilities of a facility.
(b) The facility shall arrange for the prompt
transfer of a courtesy copy of the following parts of the patient's medical
record to the receiving facility: the patient's care plan, the last two weeks
of run sheets and flow charts, a list of current medications, current treatment
orders and the last three months of clinical laboratory test results to the
receiving facility.
(c) The
facility shall have a mechanism to release copies of all or part of a patient's
medical records to the patient or to others with the written consent of the
patient or the patient's legal guardian and to others where required by law.
The facility may charge a reasonable fee for the copies so produced.
(d) The medical record for each patient shall
contain at a minimum:
1. Patient identifying
information (name, address, age, sex, marital status);
2. Dates of admission, transfer, and
discharge, as applicable;
3. Names
of referring and attending physicians;
4. Evaluation and assessment reports,
including the history and physical examination administered prior to the
initial treatment;
5. Reports from
any special examinations and consultations, and laboratory and x-ray
results;
6. Physician's
orders;
7. Care plans;
8. Signed consent forms, as
applicable;
9. Progress notes,
including dialysis flow sheets; and
10. The discharge summary, including cause of
death, if applicable.
(e)
All entries in the medical records shall be permanent, accurate, dated with the
actual date of entry, and signed by the individual making the entry. Late
entries shall be labeled as late entries.
(f) Verbal or telephone orders, if allowed by
facility policy, may only be entered by Georgia-licensed personnel, and must be
authenticated by the ordering physician or individual taking responsibility for
the order at the next patient visit or sooner as required by facility
policy.
(g) All medical record
entries shall be legible.
(h)
Medical records shall be completed within forty-five (45) days after the
patient's discharge.
Notes
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No prior version found.