Rule 111-8-29-.05 - Health Services Information System(1) The HMO and/or its providers shall establish and maintain an organized health services information system for the collection, processing, maintenance, storage and retrieval of information concerning health services received by HMO enrollees.(2) An individual record shall be maintained within the system for each enrollee to include the following minimum data: (a) Identification - name; address; identifying number; enrollment date; age and birthdate; sex; marital status; occupation; and telephone number;(b) An initial health evaluation including a chronological record of past medical history, drug use profile, personal and social history, family history and results of physical examinations, including laboratory and x-ray reports;(c) A health care plan which identifies enrollee problem(s) and need(s) and the service(s) that will be provided for the enrollee's health maintenance, including revisions as indicated;(d) The chief complaint and purpose of each visit; clinical diagnosis or impression; studies ordered; treatment given; disposition, recommendations, and instruction to patient; and a progress note for each follow-up visit;(e) Copies of all consultation and/or referral requests and responses from other health care providers within and without of the organization, which shall be entered into the health record within 14 calendar days following the completion of services by the provider; and(f) Other records, such as laboratory, x-ray and other test reports, vision/hearing records, immunization records, prenatal/postnatal records, copies of discharge summaries from inpatient health facilities, etc.(3) The system shall be kept current and available to staff or agencies authorized to use the system.(4) Health services information shall be retained for a period of six years after the last patient encounter for adults, and for six years after a minor reaches the age of majority. This information may be retained as originals, microfilms, or other usable forms and shall afford a basis for complete audit of professional information. If the HMO dissolves or changes ownership, the plan for retention shall be placed into effect and the Department shall be advised of the disposition and/or location of said records.(5) Sufficient space and equipment for record processing, storage and retrieval shall be provided.(6) Policies and procedures shall be written and implemented to assure organization and continuous maintenance of the health services information system.Ga. Comp. R. & Regs. R. 111-8-29-.05
Ga. L. 1964, pp. 499, 507, 523; Ga. L. 1979, p. 1148 et seq.; O.C.G.A. § 33-21-1et seq.
Original Rule entitled "Health Services Information System" adopted. F. Oct. 9, 2020; eff. Oct. 29, 2020.