Rule 360-41-.03. Medical Records

(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: (a) Identity of the patient; (b) History and physical, diagnosis, and treatment plan; (c) Appropriate labs, x-rays, or other diagnostic reports; (d) Appropriate pre-anesthesia evaluation; (e) Narrative description of procedure; (f) Pathology reports if relevant; (g) Documentation of which, if any, tissues and specimens have been submitted for histopathologic diagnosis; (h) Provisions for continuity of postoperative care; and (i) Documentation of the outcome and the follow-up plan. (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: (a) The type of sedation or anesthesia used; (b) Drugs (name and dose) administered and time of administration; (c) The patient's vital signs at regular intervals including, at a minimum, blood pressure, heart rate, respiratory rate and oxygen saturation; and (d) Documentation of a return to appropriate level of consciousness and readiness for discharge from acute care. Cite as Ga. Comp. R. & Regs. R. 360-41-.03
Authority: O.C.G.A. § 43-34-47.
History. Original Rule entitled "Medical Records" adopted. F. Apr. 26, 2023; eff. May 16, 2023.