Fla. Admin. Code Ann. R. 65D-30.0041 - Clinical Records

Current through Reg. 48, No. 66; April 5, 2022

(1) Record Management System. Clinical records shall be kept secure from unauthorized access and maintained in accordance with 42 Code of Federal Regulations, Part 2 and subsection 397.501(7), F.S. Providers shall have record management procedures regarding content, organization, access, and use of records.

The record management system shall meet the following additional requirements:

(a) Original clinical records shall be signed in ink and by hand or electronically;
(b) Record entries shall be legible;
(c) In instances where records are maintained electronically, a staff identifier code will be accepted in lieu of a signature;
(d) Documentation within records shall not be deleted; and
(e) Amendments or marked-through changes shall be initialed and dated by the individual making such changes.
(2) Record Retention and Disposition. In the case of individual clinical records, records shall be retained for a minimum of seven (7) years. The disposition of clinical records shall be carried out in accordance with Title 42, Code of Federal Regulations, Part 2, and subsection 397.501(7), F.S. If any litigation claim, negotiation, audit, or other action involving the records has been started before the expiration of the seven-year period, the records shall be retained until completion of the action and resolution of all issues which arise from such actions. (Juvenile Justice commitment programs and detention facilities operated by or under contract with the Department of Juvenile Justice, Inmate Substance Abuse Programs operated by or under contract with the Department of Corrections or the Department of Management Services are exempt from these requirements.) found in the Children and Families Operating Procedures (CFOP) 15-4, Records Management, and Children and Families Pamphlet (CFP) 15-7, Records Retention Schedule. Juvenile Justice Commitment Programs and detention facilities operated by or under contract with the Department of Juvenile Justice are exempt from the requirements found in the Children and Family Services Operating Procedures (CFOP) 15-4, Records Management, and the Children and Families Pamphlet (CFP) 15-7, Records Retention Schedule.)
(3) Information Required in Clinical Records.
(a) The following applies to addictions receiving facilities, detoxification, intensive inpatient treatment, residential treatment, day or night treatment with community housing, day or night treatment, intensive outpatient treatment, outpatient treatment, and methadone medication-assisted treatment for opioid addiction. Information shall include:
1. Name and address of the individual receiving services and referral source;
2. Screening information;
3. Voluntary informed consent for treatment or an order to treatment for involuntary admissions and for criminal and juvenile justice referrals;
4. Informed consent for a drug screen, when conducted;
5. Informed consent for release of information;
6. Documentation of individual orientation;
7. Physical health assessment, when conducted;
8. Psychosocial assessment, except for detoxification;
9. Diagnostic services, when provided;
10. Individual placement information, including the signature of the person who recommended placement at the level of care;
11. Abbreviated treatment plan, for addictions receiving facilities and detoxification;
12. Initial treatment plans, where indicated, and treatment plans and subsequent reviews, except for addictions receiving facilities and detoxification;
13. Progress notes;
14. Record of ancillary services, when provided;
15. Record of medical prescriptions and medication, when provided;
16. Reports to the criminal and juvenile justice systems, when provided;
17. Copies of service-related correspondence generated or received by the provider, when available;
18. Transfer summary, if transferred; and
19. A discharge summary.

In the case of clinical records developed and maintained by the Department of Corrections or the Department of Management Services on inmates participating in inmate substance abuse programs, or Juvenile Justice Commitment Programs and detention facilities operated by or under contract with the Department of Juvenile Justice, such records shall not be made part of information required in subparagraph (1)(c) above.

(b) Records regarding substance use treatment shall be made available to authorized agents of the Department only on a need-to-know basis.
(c) The following applies to aftercare. Information shall include:
1. A description of the individual's treatment episode;
2. Informed consent for services;
3. Informed consent for drug screen, when conducted;
4. Informed consent for release of information;
5. Aftercare plan;
6. Documentation assessing progress;
7. Record of ancillary services, when provided;
8. A record of medical prescriptions and medication, when provided;
9. Reports to the criminal and juvenile justice systems, when provided;
10. Copies of service-related correspondence generated or received by the provider;
11. Transfer summary, if transferred; and
12. A discharge summary.
(d) The following applies to intervention. Information shall include:
1. Name and address of individual and referral source;
2. Screening information;
3. Informed consent for services;
4. Informed consent for a drug screen, when conducted;
5. Informed consent for release of information;
6. Individual placement information, with the exception of case management;
7. Intervention plan, when required;
8. Summary notes;
9. Record of ancillary services, when provided;
10. Reports to the criminal and juvenile justice systems, when provided;
11. Copies of service-related correspondence generated or received by the provider;
12. A transfer summary, if transferred; and
13. A discharge summary.
(e) The following applies to indicated prevention. Information shall include:
1. Identified risk and protective factors for the target population;
2. Record of activities including description, date, duration, purpose, and location of service delivery;
3. Tracking of individual attendance;
4. Individual demographic identifying information;
5. Informed consent for services;
6. Prevention plan;
7. Summary notes;
8. Informed consent for release of information;
9. Completion of services summary of individual involvement and follow-up information; and
10. Transfer summary, if referred to another placement.

Notes

Fla. Admin. Code Ann. R. 65D-30.0041

Rulemaking Authority 397.321(5) FS. Law Implemented 397.321(3)(c), 397.4014, 397.410, 397.4103 FS.

Adopted by Florida Register Volume 45, Number 157, August 13, 2019 effective 8/29/2019.

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