Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.18 - Medical Records

Current through Rules and Regulations filed through June 27, 2024
(1)
Management of Patients' Medical
				Records.
The hospital shall have an efficient and organized medical
				records service that establishes the policies and procedures for the
				maintenance of the medical records for all patients and that is
				administratively responsible for the management of those records.
(a) The medical records service shall
				maintain a list of accepted abbreviations, symbols, and medical terminology to
				be utilized by persons making entries into patients' medical records.
(b) The medical records service shall utilize
				systems to verify the author(s) of entries in the patients' medical records.
				Delegation of use of computer codes, signature stamps, or other authentication
				systems, to persons other than the author of the entry, is
				prohibited.
(c) The hospital shall
				utilize systems defined by hospital policies and procedures to ensure that
				patients' medical records are kept confidential. Medical records shall be
				accessible only to hospital and medical staff involved in treating the patient
				and to other individuals as permitted by federal and state laws. The
				Department, in exercising its licensing authority, shall have the right to
				review and copy any patients' medical records.
(d) At any time during or after their course
				of treatment, patients shall be provided with copies of their medical records
				upon their written requests or the written requests of their authorized
				representatives in accordance with state law. Copies shall be provided within a
				reasonable time period not to exceed thirty (30) days after the request, unless
				the patient agrees to a lengthier delivery time. Copies of records shall be
				provided to patients for a reasonable fee in accordance with applicable
				laws.
(e) Copies of the patient's
				medical records shall be released to persons other than the patient or the
				patient's legally authorized representative either at the written request of
				the patient or as otherwise allowed by law. If the individual designated to
				receive a copy of the record is a health care provider, the copy of the record
				shall be released by the hospital in a timely manner so as not to interfere
				with the continuation of the patient's treatment.
(f) Patients' medical records shall be coded
				and indexed in a manner that allows for timely retrieval by diagnosis or
				procedure when necessary.
(g) The
				hospital shall utilize an effective process to ensure that patients' medical
				records are completed within thirty (30) days after the patients are discharged
				from the hospital. Records of other parts of patients' records that are not
				within the control of the hospital or its medical staff shall be added to the
				patients' records as soon as they become available to the hospital.
(h) The hospital shall retain all patients'
				medical records at least until the fifth anniversary of the patients'
				discharges. If the patient is a minor, the records must be retained for at
				least five (5) years past the age of majority. Records may be preserved in the
				hospital's format of choice, including but not limited to paper or electronic
				format, so long as the records are readable and capable of being reproduced in
				paper format upon request.
(i)
				Medical records shall be secured in such a manner as to provide protection from
				damage or unauthorized access.