Fla. Admin. Code Ann. R. 59A-12.005 - Medical Records System

Each HMO or PHC shall maintain or assure its providers maintain a medical records system which is consistent with professional standards and which:

(1) Permits prompt retrieval of information and provides legible and timely information accurately documented and readily available to appropriate or authorized health care practitioners;

(2) Protects the confidentiality of patient records;

(3) Records in the medical record a summary of significant surgical procedures, past and current diagnoses or problems and allergies and untoward reactions to drugs and current medications;

(4) Identifies the patient as follows:

(a) Name;

(b) Member identification number;

(c) Date of birth; and,

(d) Sex.

(5) Indicates in the medical record for each visit the following information as appropriate:

(a) Date;

(b) Chief complaint or purpose of visit;

(c) Objective findings of practitioner;

(d) Diagnosis or medical impression;

(e) Studies ordered, for example: lab, x-ray, EKG, and referral reports;

(f) Therapies administered and prescribed;

(g) Name and profession of practitioner rendering services, for example: M.D., D.O., D.C., P.D.M., R.N., O.D., etc., including signature or initials of practitioner;

(h) Disposition, recommendations, instructions to the patient and evidence of whether there was follow-up; and,

(i) Outcome of services.

(6) The HMO or PHC administrator shall be responsible for requesting consent of subscribers for release of medical records and for obtaining all documents and medical records from contracted providers necessary to carry out the provisions of chapter 641, part III, F.S., and chapter 59A-12, F.A.C.

Notes

Fla. Admin. Code Ann. R. 59A-12.005

Rulemaking Authority 641.56 FS. Law Implemented 641.495 FS.

New 1-28-88, Amended 3-11-92, Formerly 10D-100.005.

New 1-28-88, Amended 3-11-92, Formerly 10D-100.005.