Ga. Comp. R. & Regs. R. 360-41-.03 - Medical Records

(1) The physician performing office based surgery must maintain a legible, complete, comprehensive and accurate medical record for each patient. The medical record shall include:

(a) Identity of the patient;

(b) History and physical, diagnosis, and treatment plan;

(c) Appropriate labs, x-rays, or other diagnostic reports;

(d) Appropriate pre-anesthesia evaluation;

(e) Narrative description of procedure;

(f) Pathology reports if relevant;

(g) Documentation of which, if any, tissues and specimens have been submitted for histopathologic diagnosis;

(h) Provisions for continuity of postoperative care; and

(i) Documentation of the outcome and the follow-up plan.

(2) When moderate sedation/analgesia, deep sedation/analgesia, major conduction anesthesia, or general anesthesia is used, the patient's medical record shall include a separate anesthesia record which includes:

(a) The type of sedation or anesthesia used;

(b) Drugs (name and dose) administered and time of administration;

(c) The patient's vital signs at regular intervals including, at a minimum, blood pressure, heart rate, respiratory rate and oxygen saturation; and

(d) Documentation of a return to appropriate level of consciousness and readiness for discharge from acute care.

Notes

Ga. Comp. R. & Regs. R. 360-41-.03

O.C.G.A. § 43-34-47.

Original Rule entitled "Medical Records" adopted. F. Apr. 26, 2023; eff. May 16, 2023.