Medical Records (Adult Patients)

Records that document the current and complete medical record for every patient seeking care or service from an Emory healthcare provider or facility, including dental care and mental health and drug addiction counseling, multiphase clinics, hospitals, medical/nursing schools, EMS providers, and limited care residential facilities. The medical record shall contain information required for the completion of a birth, death, or stillbirth certificate and may contain the following information: identification data; chief complaint or reason for seeking care; present illness; personal and family medical history; physical examination report; provisional and pre-operative diagnosis; clinical laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; requisitions for laboratory tests; medical and surgical treatment notes and reports; evidence of appropriate informed consent; evidence of medication and dosage administered; tissue reports; physician, nurse, and therapist progress notes and reports; principal and secondary diagnoses and procedures when applicable; discharge summary; appropriate social services reports; autopsy findings; individualized treatment plans; clinical assessments of patient's needs; certification of transfer of patient between facilities; routine inquiry form regarding organ donation in the event of death; operative reports and progress notes; postoperative information; referral sources; intake interviews; orientation program documentation; mental status examination and assessments; documentation of seclusion and restraints usage; physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; when applicable, Department of Health or Children and Families’ forms for the reporting of child, elder, or domestic violence and trauma reports; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on a medical device transplant; bone marrow test reports; dialysis records; diet counseling and restriction notations; interpretations of the EEG, EKG, and fetal heart monitor tracings or if no tracings are reported - the actual tracings are included; infant screening test reports; nuclear medicine reports; x-ray interpretation records; growth charts and allergy history; emergency care rendered prior to arrival at the facility; time police or medical examiner notified; infection notices and follow-up; security notices for violent or unstable patients and accompanying family members; and adverse incident reports. Additional items may be included in the patient medical file on a case by case basis and under the recommendation of a professional or medical standards organization.

Category

Healthcare

Maintainer

Health Information Management

Retention Period

Retain for ten years from last discharge or contact that resulted in a record then dispose of.

Citations

O.C.G.A. 9-3-71; O.C.G.A. 9-3-72; O.C.G.A. 9-3-90; O.C.G.A. 9-3-91; O.C.G.A. 51-1-11

Disposition Instructions

Confidential destruction is required. Paper must be shredded, pulped, or incinerated; electronic records must be overwritten or the storage media physically destroyed. Deletion of information in computer files or on electronic storage media is not sufficient.

Last Updated: December 31, 2008