Georgia's Health Record

Health record documentation rules and regulations of Georgia State regarding the CMS requirements and the Joint Commission standard

The health record is created and maintained by the healthcare facilities which provide care and treatment to the patient. It contains details of all diagnosis and treatment procedures provided to the individual during an episode of care and must be stored in secure place to protect it from unauthorized access, theft, loss, or any other damages. The health record is used for many purposes like providing quality patient care, state registries, biomedical research, clinical education, legal procedures, etc. Each healthcare facility has its own policies and procedures of making health record forms but it should meet

According to the 290-5-8.-11 Records guidelines by the Joint Commissioner standards, the health record forms in Georgia includes the demographic information of the patient such as first, middle, and last names, address, birth date, sex (gender), marital status, religion or race, name, address, and phone number of the physician, name, address, and phone number of the person to contact in case of emergency, admission date and time, date and time for discharge or death, admitting diagnosis, final diagnosis, condition at discharge, history and physical examination records, treatment and medication orders, physicians’ and nurses’ progress notes, special examination and reports. Moreover, each facility should keep patient statistics on admission, discharge, and deaths, patient days, and percent of

CMS

The hospital creates and maintains a medical record for every individual examined or treated. A medical record should be maintained for every individual examined or treated in the hospital.

Only authorized persons can make entries in medical records. Every medical record entry should have date; its author must be identified and, when necessary, validated. All entries must be legible and complete and should be validated and dated promptly by the person who is responsible for ordering, providing, and evaluating the service provided.

The medical record should contain enough information to identify the patient, support the diagnosis and treatment; document the course and results, and promote continuity of care among healthcare provider. The medical record contains sufficient information to identify the patient, support the diagnosis and treatment, document the course and results, and promote continuity of care among healthcare providers.

All records should document all practitioners’ orders. All orders for drugs and biologicals must be in writing and signed by the practitioner and practitioners responsible for the care of the