Rule 111-8-7-.10 - Health Services Information System(1) The birth center 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 the patient.(2) An individual medical record shall be maintained within the system for each patient, and shall include the following data: (a) Identification-name, address, identifying number, date of first visit, age or birth date, sex, marital status, occupation, telephone number, and name and telephone number of a person to contact in event of an emergency;(b) An initial health evaluation including a chronological record of past medical history, drug use profile, personal and family history and results of physical examinations, including laboratory and x-ray reports;(c) A health care plan which includes information regarding each visit;(d) Clinical diagnosis or impression, studies ordered, treatment given, disposition, recommendations, and instructions to patient, complete with a progress note for each follow-up visit.(3) The system shall be kept current and available to staff or agencies authorized to use the system.(4) Medical records shall be preserved as original records, microfilms or other usable forms and shall be such as to afford a basis for complete audit of professional information. Centers shall retain all medical records or shall assure that they are maintained in a manner acceptable to the Department at least until the sixth anniversary of the patient's discharge. In the case of patients who have not attained majority at the time of the discharge, centers shall retain such records for at least six (6) years after the patient reaches age of majority. In the event a center shall cease operation, the Department shall be advised of the 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 information system.Ga. Comp. R. & Regs. R. 111-8-7-.10
O.C.G.A. § 31-2-4; O.C.G.A. § 31-7-1; O.C.G.A. Chapter 31-7, Article 1.
Original Rule entitled "Health Services Information System" adopted. F. Oct. 9, 2020; eff. Oct. 29, 2020.