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 111-8-22 - END STAGE RENAL DISEASE FACILITIES › Rule 111-8-22-.14 - Medical Records

Current through Rules and Regulations filed through June 27, 2024
(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.