Ga. Comp. R. & Regs. R. 511-7-1-.10 - Patient Records

(1) Each Health Care Provider shall maintain a current and complete Patient Record of each Patient that receives Health Care.

(2) The Health Care Provider shall maintain a record retention system that enables the proper documentation, completion, and preservation of the Patient Records of Patients who receive Health Care under the Program.

(3) Health Care Providers shall retain Patient Records for a period of at least ten years following the date of death or discharge. For pediatric patients, the records shall be retained for five years after the Patient reaches the age of majority.

(4) Patient Records shall be available for inspection only by the Health Care Provider, his or her professional staff, the Patient, representatives of the Department acting in an official capacity, DHR, DOAS, Health and Human Services, the State Attorney General, State Health Care Fraud Control Unit, applicable licensing boards, or other persons authorized in writing by the Patient to have access to the Patient Records. Patient Records requested by the Department shall be produced in accordance with Rule 511-7-1-.08(1) immediately for on-site review or sent to the Department by mail within fourteen calendar days following a request.

(5) The Health Care Provider shall release copies of all or part of a Patient Record to the Patient or to others with the written consent of the Patient or the Patient's legal guardian and to parties when required by applicable state and/or federal law. The Health Care Provider may charge a reasonable fee for the copies produced as allowable under O.C.G.A. Section 31-33-2.

(6) The Patient Record for each Patient shall contain at a minimum:

(a) Patient identifying information (name, address, age, sex, marital status, emergency contact);

(b) Department financial eligibility and patient referral forms;

(c) Name of Health Care Provider(s);

(d) Patient allergies;

(e) Diagnosis of the Patient's condition;

(f) Reports from diagnostic testing;

(g) Physician orders;

(h) Documentation that the Patient has consented to the Health Care, as well as the signed acknowledgment required by Rule 511-7-1.09; and

(i) Information justifying the treatment or procedure provided and a report of outcomes of treatment or procedures.

(7) All entries in the Patient Records shall be permanent, accurate, dated with the actual date of entry, and signed by the individual making the entry.

(8) Patient Records shall be completed within thirty days after Health Care has been provided to the Patient.

(9) Health Care Providers must comply with the requirements set forth in the Health Insurance Portability and Accountability Act of 1996 with respect to the handling of Patient Records, as well as with any other applicable federal and state laws and rules and regulations.

Notes

Ga. Comp. R. & Regs. R. 511-7-1-.10

O.C.G.A. Secs. 31-2A-6, 31-8-200.

Original Rule entitled "Patient Records" adopted. F. Sep. 20, 2013; eff. Oct. 10, 2013.