Fla. Admin. Code Ann. R. 64B15-15.004 - Written Records; Minimum Content; Retention
(1) For the purpose of
implementing the provisions of Section
459.015(1)(o),
F.S., osteopathic physicians shall maintain written legible records on each
patient in English, with sufficient detail to clearly demonstrate why the
course of treatment was undertaken. The 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. Such
written records shall contain, at a minimum, the following information about
the patient:
(a) Patient histories;
(b) Examination results;
(c) Test results;
(d) Records of drugs prescribed, dispensed or
administered;
(e) Reports of
consultations;
(f) Reports of
hospitalizations; and,
(g) 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.
(2) Medical records in which compounded
medications are administered to a patient in an office setting must contain, at
a minimum, the following information:
(a) The
name and concentration of medication administered;
(b) The lot number of the medication
administered;
(c) The expiration
date of the medication administered;
(d) The name of the compounding pharmacy or
manufacturer;
(e) The site of
administration on the patient;
(f)
The amount of medication administered; and,
(g) The date medication
administered.
(3) All
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.
(4) Whenever patient records are released or
transferred, the osteopathic physician releasing or transferring the records
shall maintain either the original records or copies thereof and a notation
shall be made in the retained records indicating to whom the records were
released or transferred. However, whenever patient records are released or
transferred directly to another Florida licensed physician, or licensed health
care provider it is sufficient for the releasing or transferring osteopathic
physician to maintain a listing of each patient whose records have been so
released or transferred which listing also includes the physician or licensed
health care provider to whom such records were released or transferred. Such
listing shall be maintained for a period of five (5) years.
(5) In order that the patients may have
meaningful access to their records pursuant to Section
456.058, F.S., an osteopathic
physician shall maintain the written record of a patient for a period of at
least five (5) years from the date the patient was last examined or treated by
the osteopathic physician. However, upon the death of the osteopathic
physician, the provisions of Rule
64B15-15.001, F.A.C., are
controlling, and when an osteopathic physician terminates practice or relocates
and is no longer available to patients, the provisions of Rule
64B15-15.002, F.A.C., are
controlling.
Notes
Rulemaking Authority 456.058, 459.005 FS. Law Implemented 456.058, 459.015(1)(o) FS.
New 11-30-94, Amended 10-25-95, Formerly 59W-15.004, Amended 12-22-97, 9-9-13, 3-8-18, 11-29-22.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.