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 111-8-56 - NURSING HOMES
Rule 111-8-56-.11 - Records

Universal Citation: GA Rules and Regs r 111-8-56-.11

Current through Rules and Regulations filed through September 23, 2024

(1) Each home shall maintain a complete medical record on each patient containing sufficient information to validate the diagnosis and to establish the basis upon which treatment is given. All active medical records shall be maintained at the nurses' station. The completed record shall normally contain the following:

(a) Name, address, birth date, sex, marital status of the patient and religion; the name, address and telephone number of physician; the name, address and telephone number of the responsible party to contact in emergency;

(b) Date and time of admission;

(c) Date and time of discharge or death;

(d) Admitting diagnosis;

(e) Final diagnosis;

(f) Condition on discharge;

(g) History and physical examination;

(h) Treatment and medication orders;

(i) Physicians' progress notes (at least monthly);

(j) Nurses' notes;

(k) Special examination and reports.

(2) Each home shall keep patient statistics, including admissions, discharges, deaths, patient days, and percent of occupancy. Statistical records shall be open for inspection and upon request, data shall be submitted to the Department.

O.C.G.A. §§ 31-2-4et seq. and 31-7-1 et seq.

Disclaimer: These regulations may not be the most recent version. Georgia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.