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.

Category

Healthcare

Maintainer

Health Information Management

Retention Period

Retain until patient's 23rd birthday or 10 years from last discharge or contact, whichever is longer.

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