(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.
O.C.G.A. §
31-44-3.
