Rule 360-41-.03. Medical Records

1. (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:

   1. (a) Identity of the patient;
   2. (b) History and physical, diagnosis, and treatment plan;
   3. (c) Appropriate labs, x-rays, or other diagnostic reports;
   4. (d) Appropriate pre-anesthesia evaluation;
   5. (e) Narrative description of procedure;
   6. (f) Pathology reports if relevant;
   7. (g) Documentation of which, if any, tissues and specimens have been submitted for histopathologic diagnosis;
   8. (h) Provisions for continuity of postoperative care; and
   9. (i) Documentation of the outcome and the follow-up plan.

2. (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:

   1. (a) The type of sedation or anesthesia used;
   2. (b) Drugs (name and dose) administered and time of administration;
   3. (c) The patient's vital signs at regular intervals including, at a minimum, blood pressure, heart rate, respiratory rate and oxygen saturation; and
   4. (d) Documentation of a return to appropriate level of consciousness and readiness for discharge from acute care.

Authority: O.C.G.A. § 43-34-47.

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