Ga. Comp. R. & Regs. R. 111-8-37-.23 - Medical Records

(1) In accordance with accepted standards of practice, the hospice must establish and maintain a medical record for every patient admitted for care and services. The medical record must be complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval and to support the provision of patient care.

(2) Entries must be made for all services provided and must be signed and dated on the day of delivery by the individual providing the services for inclusion in the patient's medical record within seven days. The record must include all services whether furnished directly or under arrangements made by the hospice.

(3) Each patient's medical record must contain:

(a) Identification data;

(b) The initial and subsequent assessments;

(c) Pertinent medical and psychosocial history;

(d) Consent and authorization forms;

(e) The interdisciplinary plan of care;

(f) The name of the patient's attending physician; and

(g) Complete documentation of all services and events, including evaluations, treatments, progress notes, transfers, discharges, etc.

(4) The hospice must have the patient's medical record readily accessible and must safeguard the medical record against loss, destruction, and unauthorized use.

(5) Medical records must be preserved as original records, microfilms, or other usable forms and must be such as to afford a basis for complete audit of professional information. Hospices must retain all medical records at least until the sixth anniversary of the patient's death or discharge, and as otherwise required by law. If the patient is a minor, medical records must be retained for at least five years past the age of majority or, in the event the minor patient dies, for at least five years past the year in which the patient would have reached the age of majority. In the event the hospice ceases operation, the hospice must provide prior notice to the local community, referring providers and the Department of the location of the medical records and how such records may be retrieved.

Notes

Ga. Comp. R. & Regs. R. 111-8-37-.23

O.C.G.A. §§ 31-7-170et seq.

Original Rule entitled "Medical Records" adopted. F. May 26, 2015; eff. June 15, 2015.