Current through Reg. 47, No. 249; December 28, 2021
Medical records are maintained for the
(a) To serve as a basis
for planning patient care and for continuity in the evaluation of the patient's
condition and treatment.
furnish documentary evidence of the course of the patient's medical evaluation,
treatment, and change in condition.
(c) To document communication between the
practitioner responsible for the patient and any other health care professional
who contributes to the patient's care.
(d) To assist in protecting the legal
interest of the patient, the hospital, and the practitioner responsible for the
(2) A licensed
physician shall maintain patient medical records in English, in a legible
manner and with sufficient detail to clearly demonstrate why the course of
treatment was undertaken.
medical record shall contain sufficient information to identify the patient,
support the diagnosis, justify the treatment and document the course and
results of treatment accurately, by including, at a minimum, patient histories;
examination results; test results; records of drugs prescribed, dispensed, or
administered; reports of consultations and hospitalizations; and copies of
records or reports or other documentation obtained from other health care
practitioners at the request of the physician and relied upon by the physician
in determining the appropriate treatment of the patient.
Medical records in which compounded
medications are administered to a patient in an office setting must contain, at
a minimum, the following information:
name and concentration of medication administered;
(b) The lot number of the medication
(c) The expiration
date of the medication administered;
(d) The name of the compounding pharmacy or
(e) The site of
administration on the patient;
The amount of medication administered; and
(g) The date medication
entries made into the medical records shall be accurately dated and timed. Late
entries are permitted, but must be clearly and accurately noted as late entries
and dated and timed accurately when they are entered into the record. However,
office records do not need to be timed, just dated.
(6) In situations involving medical
examinations, tests, procedures, or treatments requested by an employer, an
insurance company, or another third party, appropriate medical records shall be
maintained by the physician and shall be subject to Section
F.S. However, when such examinations, tests, procedures, or treatments are
pursuant to a court order or rule or are conducted as part of an independent
medical examination pursuant to Section
or 627.736(7), F.S., the record maintenance requirements of Section 456.061,
F.S., and this rule do not apply. Nothing herein shall be interpreted to permit
the destruction of medical records that have been made pursuant to any
examination, test, procedure, or treatment except as permitted by law or
Fla. Admin. Code Ann. R.
FS. Law Implemented
New 1-1-92, Formerly
21M-27.003, Amended 1-12-94, Formerly 61F6-27.003, Amended 9-3-95, Formerly
59R-9.003, Amended 8-20-02. 9-11-06,