Guide to Business Records Retention Requirements

O.C.G.A. Title 31-- HEALTH

AMBULANCE SERVICE
AMBULATORY SURGICAL TREATMENT CENTERS
BEDDING, ARTICLES OF
BIRDS OF THE PSITTACINE FAMILY, IMPORTATION, PURCHASE, BREEDING, GIVING AWAY, SALE OR OFFER OF SALE OF
BIRTH CENTERS
BLOOD
EMERGENCY MEDICAL SERVICES
EYE BANKS
FUNERAL DIRECTORS
HOSPICES

HOSPITALS
DISASTER PREPAREDNESS PLANS
MEDICAL RECORDS

HEALTH CARE PROVIDERS

RESIDENTIAL INTENSIVE TREATMENT FACILITIES
INTERMEDIATE CARE HOMES
NURSING HOMES
PERSONAL CARE HOMES RADIATION CONTROL AND RADIOACTIVE MATERIALS TRAUMATIC BRAIN INJURY FACILITIES

Ambulance Service

Citation: Rule 290-5-30-.05 Records of Ambulance Service Providers. Amended.
Regulating Agency: The Department of Human Resources.
Requirement: (1) to make records of each ambulance response in a manner, frequency, and on such printed or electronic prehospital care report forms as may be approved by the department, which reports must be signed by the emergency medical technicians and the licensed physician or licensed professional nurse or paramedic receiving the patient; (2) to maintain training records for each employee containing pertinent information regarding licensing as a medic, and any other department required courses; (3) to maintain a dispatch record of all calls received, including but not limited to the date and time call was received, patient's name (or source of call if patient's name is unknown), call back telephone number, location of patient, apparent problem(s), unit dispatched and time of dispatch, time arrived at scene, time left scene, destination of patient, and time arrived at patient's destination.
Persons Affected: Persons operating ambulance services in the State of Georgia.
Retention Period: With respect to prehospital care report, permanently (in patient's medical records); with respect to dispatch report, three years; with respect to other records, not specified.
Related Code Sections: O.C.G.A. Sections 31-11-5 and 31-11-6.

Ambulatory Surgical Treatment Centers

Citation: Rule 290-5-33-.12 Records.
Regulating Agency: Department of Human Resources.
Requirement: (1) to maintain medical records on each patient containing sufficient information to validate the diagnosis and to establish the basis upon which treatment is given (The minimum requirements for such records are extensive; see the text of the Rule for details); and (2) to collect, retrieve, and annually summarize data from the medical records, including number of visits by patients, number of patients seen, basis of treatment (clinical diagnosis and/or problem for which the patient was treated), types and number of operative procedures performed, age distribution of patients, complications and emergencies, number of times a patient was transferred from the center to a hospital, and pathological diagnosis.
Persons Affected: Ambulatory surgical treatment centers.
Retention Period: With respect to all medical records, at least until the sixth anniversary of the patient's discharge; with respect to patients who have not attained majority at the time of discharge, at least six years after the patient reaches the age of majority. With respect to the statistical data, until the data is turned over to the Department of Human Resources (which is done on an annual basis).
Related Code Sections: O.C.G.A. Sections 31-6-2, 31-7-2, 31-7-2.1, and 31-7-280.

Bedding, Articles of

Citation: Rule 40-19-1-.06(4)(a) Sterilization.
Regulating Agency: Commissioner of Agriculture.
Requirement: To keep carefully filed recording thermometer charts on which operators of the sterilizing chamber shall initial and date each sterilization period.
Persons Affected: Manufacturers, renovators, and reupholsterers using previously-used materials and persons selling secondhand articles of bedding.
Retention Period: One year.
Related Code Sections: O.C.G.A. Section 31-25-8.

Birds of the Psittacine Family, Importation, Purchase, Breeding, Giving Away, Sale or Offer of Sale of

Citation: Rule 290-5-1-.07 Records. Amended.
Regulating Agency: Department of Human Resources.
Requirement: To keep a permanent record of all purchases, sales, and transfers of birds, which record must include the identifying number of the band of each bird, the full name and address of each person or persons receiving a bird from the permit holder by sale, transfer, or gift.
Persons Affected: Each breeder and dealer of birds of the psittacine family.
Retention Period: Permanent.
Related Code Sections: O.C.G.A. Section 31-12-9.

Birth Centers

Citation: Rule 290-5-41-.06 Organization and Administration.
Regulating Agency: Department of Human Resources.
Requirement: To have: (1) written policies and procedures for antepartum, intrapartum, postpartum, and newborn care, including physician consultation, referral, transfer and transport to the hospital and registration of vital records; (2) a written procedure maintain the written policies and procedures; and (3) a written policy regarding visitation or attendance during the birth process.
Persons Affected: Birth centers.
Retention Period: Not stated.
Related Code Sections: O.C.G.A. Sections 31-2-4 and 31-7-1.

Citation: Rule 290-5-41-.08 Professional Services.
Regulating Agency: Department of Human Resources.
Requirement: To have: (1) written policies and procedures for emergency services to patients; and (2) written policies and procedures to ensure (a) metabolic screening of all newborns within one week of age, (b) assessment of newborn status, including Apgar score at one and five minutes, (c) prevention of eye infection, (d) umbilical cord care, and (e) periodic observation and assessment after birth until the infant;s condition is stable.
Persons Affected: Birth centers.
Retention Period: Not stated.
Related Code Sections: O.C.G.A. Sections 31-2-4 and 31-7-1.

Citation: Rule 290-5-41-.09 Personnel.
Regulating Agency: Department of Human Resources.
Requirement: To maintain a separate personnel folder for each employee containing all pertinent information concerning the employee, including: (1) the application for employment and qualifications for employment; (2) verifications of physical examinations; (3) job description; and (4) a copy of current Georgia license for those required to be licensed.
Persons Affected: Birth centers.
Retention Period: Not stated.
Related Code Sections: O.C.G.A. Sections 31-2-4 and 31-7-1.

Citation: Rule 290-5-41-.10 Health Services Information System.
Regulating Agency: Department of Human Resources.
Requirement: (1) To establish and maintain an organized health services information system for the collection, processing, maintenance, storage, and retrieval of information concerning health services received by patients, with each individual record, at the minimum, including: (a) identification (name, address, identifying number, date of first visit, age or birthdate, sex, marital status, occupation, telephone number, and name and telephone number of person to contact in event of an emergency); (b) an initial health evaluation including a chronological record of past medical history, drug use profile, personal and family history, and results of physical examinations, including laboratory and x-ray reports; (c) a health care plan which includes information regarding each visit; (d) clinical diagnosis or impression; studies ordered; treatment given; disposition, recommendations, and instruction to patient; and a progress note for each follow-up visit; and (2) to have and implement written policies and procedures to assure organization and continuous maintenance of the health services information system.
Persons Affected: Birth centers.
Retention Period: With respect to adult patients, for a period of six (6) years after the last patient encounter; with respect to patients who are minors, for six (6) years after a minor reaches the age of majority.
Related Code Sections: O.C.G.A. Sections 31-2-4 and 31-7-1.

Blood

Citation: O.C.G.A. Section 31-24-5(b) Transfusion of unlabeled blood; identification of blood administered by transfusion.
Regulating Agency: Department of Human Resources.
Requirement: To record in a patient's medical record the identification number of the unit of blood when blood is administered by transfusion.
Persons Affected: Any person administering blood by transfusion in the State of Georgia.
Retention Period: Not stated.
Related Code Sections: O.C.G.A. Section 31-24-1 and the sections following.

Citation: Rule 290-5-34-.04 Unlabeled Blood, Medical Record, Removal of Label.
Regulating Agency: Department of Human Resources.
Requirement: (1) To maintain in the blood bank accepting blood a record to identify the source of each unit as by "donation" or "purchase"; and (2) to record (by a person authorized to administer blood) in a patient's medical record the identification numbers of the unit(s) of blood transfused, with records accompanying each unit of blood or blood products leaving a blood bank to indicate whether such unit was acquired by donation or purchase.
Persons Affected: Blood banks and any person administered blood by transfusion in the State of Georgia.
Retention Period: Not stated.
Related Code Sections: O.C.G.A. Section 31-24-1 and the sections following.

Emergency Medical Services

Citation: O.C.G.A. Section 31-11-6 Records.
Regulating Agency: Department of Human Resources.
Requirement: To make records of each ambulance trip in a manner and on such forms as may be prescribed by the Department of Human Resources through regulations.
Persons Affected: Agencies or companies providing ambulance service which are operating under a valid license from the Emergency Health Section of the Division of Physical Health of the Department of Human Resources.
Retention Period: Not specified.

Eye Banks

Citation: Rule 290-5-7-.07 Records. Amended.
Regulating Agency: Department of Human Resources.
Requirement: To keep: (1) donor record, containing the signed and witnessed duplicate donor card of every intended donor and the consent form (witnessed by two persons of legal majority) for every eye received in the eye bank; and (2) history record of the enucleation, identification, and condition of the eye or eyes, including a full medical history, cause of death, time of death, record time of enucleation, and, when available, gross and slit lamp examination of the enucleated eye.
Persons Affected: Eye banks.
Retention Period: A minimum of six years.
Related Code Sections: O.C.G.A. Section 31-2-4.

Funeral Directors

Citation: Rule 290-1-3-.36 Funeral Directors' Records.
Regulating Agency: Department of Human Resources.
Requirement: To keep a record containing, as a minimum, the following information about each dead body or fetus the funeral director disposes of: (1) the date, place, and time of receipt; (2) the date, place, and manner of disposition; (3), if the dead body or fetus is delivered to another funeral director, the date of such delivery and the name and address of the funeral director to whom delivered; (4) the items required by the certificate of death for those deaths for which the funeral director was required to file the certificate.
Persons Affected: Funeral directors.

Hospices

Citation: Rule 290-5-43-.15 Records.
Regulating Agency: Department of Human Resources.
Requirement: To keep: a clinical record including (1) identification data; (2) the initial and subsequent assessments; (3) the plan of care; (4) consent and authorization forms; (5) pertinent medical and psychosocial history; (5) complete documentation of all services and events; and (6) transfer and discharge records.
Persons Affected: Hospices.
Retention Period: Sixth anniversary of patient's death or discharge.
Related Code Sections: O.C.G.A. Section 31-7-8.

Hospitals

Citation: Rule 290-9-7-.18 Medical Records.
Regulating Agency: Department of Human Resources.
Requirement: To keep medical records for inpatients and outpatients. Requirements are extensive; refer to rule for specifics.
Persons Affected: Hospitals.
Retention Period: Not specified.
Related Code Sections: O.C.G.A. Section 31-7-2.1.

Citation: Rule 290-9-7-.15 Disaster Preparedness.
Regulating Agency: Department of Human Resources.
Requirement: To keep: an effective disaster preparedness plan that identifies emergency situations and outlines an appropriate course of action.
Persons Affected: Hospitals.
Retention Period: Must be reviewed and revised annually.
Related Code Sections: O.C.G.A. Section 31-7-2.1.

Health Care Providers

Citation: O.C.G.A. 31-33-2
Regulating Agency: Department of Human Resources
Requirement: To retain patient evaluations, diagnoses, prognoses, laboratory reports, or biopsy slides.
Persons Affected: Health care providers.
Retention Period: Not less than ten years.
Related Code Sections: O.C.G.A. Section 31-33-1.

Residential Intensive Treatment Facilities

Citation: Rule 290-4-2-.20 Residential Intensive Treatment Programs.
Regulating Agency: Department of Human Resources.
Requirement: To keep a written agreement with a physician for the provision of medical care.
Persons Affected: Residential Intensive Treatment Facilities.
Retention Period: Not specified.
Related Code Sections: O.C.G.A. Section 31-7-2.1.

Intermediate Care Homes

Citation: Rule 290-5-9-.03 Administration.
Regulating Agency: Department of Human Resources.
Requirement: To keep: (1) a written transfer agreement one or more hospitals or nursing homes; (2) a separate personnel file for each employee containing all personal information including application and qualifications for employment, physical examination, and job title assigned; (3) a current job description for each classification of employee.
Persons Affected: Intermediate Care Homes.
Retention Period: Not specified.

Nursing Homes

Citation: Rule 290-5-8-.03 Administration.
Regulating Agency: Department of Human Resources.
Requirement: To keep: (1) a written transfer agreement one or more hospitals; (2) a separate personnel file for each employee containing all personal information including application and qualifications for employment, physical examination, and job title assigned; (3) a current job description for each classification of employee; (4) documentation of successful completion of the dining assistant training program for each dining assistant.
Persons Affected: Nursing Homes.
Retention Period: Not specified.
Related Code Sections: O.C.G.A. Section 31-7-1.

Personal Care Homes

Citation: Rule 290-5-35-.17 Resident Files.
Regulating Agency: Department of Human Resources.
Requirement: To keep an individual resident file. Requirements are extensive; please refer to text of the rule.
Persons Affected: Personal Care Homes.
Retention Period: Three years after resident's discharge.
Related Code Sections: O.C.G.A. Section 31-7-2.1.

Radiation Control and Radioactive Materials

Citation: Rule 290-5-22-.07 Records, Reports and Notification. Amended.
Regulating Agency: Department of Human Resources.
Requirement: To retain records: (1) showing the radiation exposures of all individuals for whom personnel monitoring is required; these records shall be for periods of time not exceeding one calendar quarter; (2) showing the results of surveys, saftey checks, and calibrations; (3) showing the receipt, transfer, or disposal of radiation machines; (4) of all major maintenance and/or modifications performed on each radiation machines including but not limited to tube housing or x-ray tube insert replacement, any reorientation of the machine, repair or change of the console or high-voltage supply, or collimator repair.
Persons Affected: Registered users of radiation machines.
Retention Period: For (1), five years after termination of the individual's employment or association with registrant or such other time as the Department may determine; for (2), (3), and (4), retention period not specified.
Related Code Sections: O.C.G.A. Section 31-13.

Traumatic Brain Injury Facilities

Citation: Rule 290-5-53-.10 Recordkeeping.
Regulating Agency: Department of Human Resources.
Requirement: To keep an individual care record for each client containing: (1) case identification information; (2) names, addresses, and telephone numbers of responsible family members, guardians, or representatives; (3) name, addresses, and telephone numbers of emergency contacts to include the client's physicians; (4) admissions documentation; (5) client's complete written assessment; (6) client's written program plan, including the designation of a case manager; and (7) signed and dated progress reports, notes, or similar documentation related to the mental and physical health, treatment, and rehabilitation of the client to include current drug regimens, treatment, and dietary needs.
Persons Affected: Traumatic Brain Injury Facilities.
Retention Period: Not specified.
Related Code Sections: O.C.G.A. Section 31-7-2.1.