GA · guidance
Ga. Medicaid Part II Policies & Procedures for Hospital Services § 903
All Medical Records must contain the information listed below:
903.1. Identification of the patient.
903.2. Medical history of the patient.
903.3. Report of relevant physical examination
903.4. Diagnostic and therapeutic orders.
903.5. Evidence of appropriate informed consent.
903.6. Clinical observations, including the results of therapy.
903.7. Reports and results of procedures and tests.
903.8. Conclusions at termination of hospitalization, evaluation or treatment.
903.9. Condition of the patient upon discharge and instructions given to the patient and family.
903.10. Signature and date for each entry.
Provenance
- Source
- www.mmis.georgia.gov
- Retrieved
- 2026-10-01
- Edition
- pp-hospital-2026-10-01
- Content hash
26e5c40550d469ffd73a26723f9e68759099cfae54f1131f9bcfe66e8c88c6d3
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