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 111-8-71 - TRAUMATIC BRAIN INJURY FACILITIES
Rule 111-8-71-.10 - Recordkeeping
Current through Rules and Regulations filed through September 23, 2024
An individual care record shall be maintained for each client admitted to the facility. Case records must be maintained in a central location, and contain the following materials:
(a) Case identification information;
(b) Names, addresses, and telephone numbers of responsible family members, guardians, or representatives;
(c) Names, addresses, and telephone numbers of emergency contacts to include the client's physicians;
(d) Admissions documentation;
(e) The client's complete written assessment;
(f) The client's written program plan, including the designation of a case manager; and
(g) Signed and dated progress reports, notes or similar documentation related to the mental and physical health, treatment, and rehabilitation of the client to include current drug regimens, treatment, and dietary needs.
O.C.G.A. § 31-7-2.1.
