Medical records under the Department of Community Health regulations - GA. COMP. R. & REGS. § 111-8-40-.18

Hospitals must retain patient records for 5 years. In the case of a minor patient, medical records must be retained 5 years after a patient turns 18 years old.
 
Hospital records must be kept confidential, and only accessible to staff involved in treating the patient, and to others as permitted by law.
 
Patients shall be provided copies of their medical records upon their written request, or the written request of their authorized representatives. Copies must be provided within thirty days unless the patient consents to a longer delivery time. Copies may be provided for a reasonable fee.
 
Copies of the patient’s records may only be released to persons other than the patient or the patient’s representative with the written consent of the patient, or as otherwise permitted by law.
 
Hospital records should be completed within thirty days after discharge. Records should be secured in a manner to protect them from damage or unauthorized access.
 
Entries should be legible and should support the diagnosis and treatment.
 
Inpatient records should contain the following information:
·         Patient identifying information, including name and contact information
·         Date and time of admission
·         Diagnosis and symptoms
·         Name of physician
·         Patient allergies
·         Advanced directives
·         History and physical examination
·         Report of nursing assessment
·         Laboratory and other assessment data or reports
·         Consultation reports
·         Plan of care
·         Physician orders
·         Progress notes
·         Medication and treatment records
·         Informed consent documentation
·         Date of discharge
·         Disposition/final diagnosis
·         Discharge summary
·         Autoposy results
 
Outpatient records should contain the following information:
·         Patient identifying information, including name and contact information
·         Diagnosis
·         Name of physician
·         Patient allergies
·         Physician orders
·         Informed consent documentation
·         Reports from diagnostic testing
·         Sufficient information to justify treatment, report of outcomes and disposition after treatment