Fla. Admin. Code Ann. R. 59A-18.012 - Clinical Records
The licensed nurse responsible for the delivery of skilled patient care shall maintain a clinical record, pursuant to section 400.497(8), F.S., for each patient receiving nursing services in the home that shall include, at a minimum, the following:
(1) Identification sheet containing the
patient's name, address, telephone number, date of birth, sex, and caregiver or
guardian;
(2) Before information can
be released, an authorization for such release must be dated and signed by the
patient, caregiver, or guardian;
(3)
Plan of treatment as required in section
400.506(13),
F.S.;
(4) Clinical and service
notes, signed and dated by the nurse providing the service which shall include:
(a) Any assessments by a registered
nurse;
(b) Progress notes with
changes in the person's condition;
(c) Services provided;
(d) Observations; and,
(e) Instructions to the patient and
caregiver;
(5) Reports to
physicians;
(6) Termination summary
including:
(a) The date of the first and last
visit;
(b) The reason for
termination of services;
(c) An
evaluation of established goals at time of termination;
(d) The condition of the patient at the time
of termination of services; and,
(e) The referral for additional services when
the patient requires continuing services.
(7) Each nurse registry shall keep clinical
records received from the independent contractor licensed nurse for 5 years
following the termination of service. Retained records can be stored as hard
paper copy, microfilm, computer disks or tapes and must be retrievable for use
during unannounced surveys.
(8) The
nurse registry is not obligated to review patient or client records per section
400.506(20),
F.S., but the nurse registry is not prohibited from reviewing records and may
do so. In the event of violation of state law which comes to the attention of
the nurse registry, the nurse registry shall take the actions specified in
section 400.506(19),
F.S.
Notes
Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS.
New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 5-4-15.
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