Healthcare

Assisted Reproductive Technology (ART), Embryology, and Sperm Bank Records

This series documents fertility efforts undertaken through use of a sperm bank, embryology, and assisted reproductive technology (ART).

Emergency Department

This series documents the intake and transfer of patients to and from the emergency department to an Emory Healthcare provider or facility. This series may include, but is not limited to: logs, patient index, on-call schedules, staffing schedules, and transfer records.

Equipment Records

This series documents equipment maintenance and functioning. This series may include, but is not limited to: calibration and validation, maintenance and inspection, operating instructions and manuals.

Immunohematology

This series documents testing and quality control for transfusion services, including donor processing, compatibility testing, and transfusion reaction investigations.

Laboratory Errors

This series documents the request, results, and correction of cytology, histopathology, and pathology reports. This series may include, but is not limited to: request forms, diagrams, registers, and reports.

Laboratory Errors

This series documents inadequately prepared slides, unsatisfactory specimens, and associated notifications in Cytology labs.

Medical Records: Adults

This series documents the medical history of adults seeking care or service from an Emory Healthcare provider or facility. This series may include, but is not limited to: personal and family medical history; physical examination report; laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; medical and surgical treatment notes and reports; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; discharge summary; treatment plans; operative and postoperative reports and progress notes; mental status examination and assessments; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on medical device transplant; bone marrow test reports; dialysis records; interpretations of the EEG, EKG, and fetal heart monitor tracings; nuclear medicine reports; x-ray interpretations; autopsy findings; and death certificate.

Medical Records: Index

This series documents patient identification, registration, medical, and billing information for each individual registered at the hospital. This series may include, but is not limited to: demographic data, encounter data, and admissions, discharge, transfer (ADT) data.

Medical Records: Minors

This series documents the medical history of minors seeking care or service from an Emory Healthcare provider or facility. This series may include, but is not limited to: personal and family medical history; physical examination report; laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; medical and surgical treatment notes and reports; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; discharge summary; treatment plans; operative and postoperative reports and progress notes; mental status examination and assessments; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on medical device transplant; bone marrow test reports; dialysis records; interpretations of the EEG, EKG, and fetal heart monitor tracings; nuclear medicine reports; x-ray interpretations; autopsy findings; and birth or death certificate.

Operating Room Records

This series documents the use of a facility's operating room. This series may include, but is not limited to: charge sheets, reports, and schedules.

Organ Donation Logs

This series documents the evaluation and determination of potential organ donor and recipient suitability.

Proficiency Testing Records

This series documents proficiency testing and remedial actions taken in the event of an unacceptable score.

Pump Records

This series documents the calibration, maintenance and inspection of pumps. This series may include, but is not limited to: operating instructions and manuals.

Quality Assurance Records

This series documents the process of requesting or maintaining a national, state, or other mandatory or voluntary accreditation, certificate, or license, and the documentation related to the approval or denial. This series may include, but is not limited to: questionnaires, surveys, planning documents, performance measures, and statistics.

Quality Control Records

This series documents quality control programs enacted to ensure that accurate test results are reported. This series may include, but is not limited to: performance specifications, requisitions, instrument documentation, and specimen identification and tracking records.

Staffing Patterns and Schedules

This series documents staff plans for nurses, social workers, and/or other medical staff. This series may include, but is not limited to: staff schedules.

Sterilization Records

This series documents the testing of facilities or equipment for infectious substances, and the sterilization of equipment or materials for medical use. This series may include, but is not limited to: sterilization graphs and autoclave records.

Tissue Bank Records

This series documents the harvesting, processing, storage and transportation of human tissues. This series may include, but is not limited to: requisitions, authorizations, test procedures, and analytic system records.

Validation of Quantitative Methods

This series documents the validation of methods of analysis adopted and the assessment of the results of such validation work. This series may include, but is not limited to: procedures and results.