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.

Category

Healthcare

Maintainer

Health Information Management

Retention Period

Retain 10 years from last discharge or contact.

Citations

Ga. Comp. R. & Regs. 111-8-40-.18(1)(h); O.C.G.A. 31-33-2 ; 42 CFR 482.24(b)(1)

Disposition Instructions

Confidential destruction is required. Paper must be shredded 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: August 21, 2017