Compilation of Rules and Regulations of the State of Georgia
Department 82 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES
Chapter 82-5 - PATIENT'S RIGHT
Subject 82-5-1 - PATIENT'S RIGHT
Rule 82-5-1-.06 - Clinical Records

(a) A clinical record shall be maintained at each facility for each individual treated at that facility, containing protected health information of the individual. The record shall contain information on all matters relating to the admission, care, treatment, discharge, and legal status of the individual, and shall include all medical and legal documents relating to the individual. The record shall not contain peer review or administrative documents such as incident reports and investigations of incidents or complaints. The record specifically shall contain at least the following: progress notes; documents describing or arising from the individual's history; the results of all psychiatric, psychological, and physical examinations; individualized service plans; evaluations other than evaluations developed at the direction of a court that is assessing an individual's competence or responsibility under O.C.G.A. Title 17, Chapter 7, which are not to be maintained in the medical record; orders for treatment; orders for physical restraints, seclusion, and other restrictions permitted by these regulations or other applicable law; clinical documentation of accidents and incidents and of follow-up care provided; court orders establishing guardianship of the individual if applicable; advance directives of the individual if possible; and court orders and other court documents received by the facility. When clinical records or parts of clinical records are released as provided in this section, copies of the clinical record should be released. If the record is electronic, a tangible copy may be produced as legally sufficient for purposes of disclosures, except as otherwise provided in this section. The name(s) or other identifying information of other individuals who are receiving or formerly received treatment or services may not be recorded in an individual's clinical record. The initials of another individual may be recorded if necessary.

(a) The Department shall create and enact policies that implement the rules relating to confidentiality contained in HIPAA and in federal substance abuse confidentiality laws and regulations. Staff shall comply with applicable confidentiality provisions established by Georgia law.

(a) Every individual currently or formerly admitted to a facility shall have the right to examine all clinical records kept in that individual's name by the Department or the facility where the individual is or was hospitalized or treated; provided, however, that if the individual is currently admitted to the facility, the individual shall not have the right to examine such clinical records if:

(b) Each facility shall assist individuals in reviewing their own records but may establish reasonable limitations, such as those relating to time, place, and frequency, upon such review.

(a) Every individual currently or formerly admitted to a facility shall have the right to request that any inaccurate information found in the individual's clinical record be corrected. A request from an individual currently admitted to a facility shall be made in writing to the person in charge of records at the facility or to another person designated by the superintendent. That person will consult the appropriate staff at the facility if needed. If the request is made orally to a staff member, that staff member will assist the individual in making the request to the appropriate person.

(b) Upon receipt of a request for correction of the record of an individual currently or formerly admitted to the facility, the person in charge of records at the facility or the person so designated shall within 5 days:

(c) If amendments are made to the records of an individual currently or formerly admitted to a facility, they should be added to the record and the original record should be preserved.

(a) It is the policy of the Department to provide routine information to the general public in compliance with the Georgia Open Records Act or DBHDD policy regarding medical records.

(b) Fees charged for copying services in State facilities shall comply with policies set by the Department.

(c) Waiver or reduction of fees may be granted where such action is in the public interest or when based on an individual's ability to pay.

(d) Staff members shall assist the individual in the selection of records for copying purposes. A policy of full disclosure and assistance shall be followed, while waste in copying practices is to be discouraged.