Current through Reg. 50, No. 187; September 24, 2024
(1) The insurer or delegated entity shall
implement a system for managing electronic and paper medical information
necessary to promote the prompt delivery of medical services in order to return
the injured employee to work as soon as medically feasible.
(2) Provider Medical Records. The insurer or
delegated entity shall maintain or assure that its providers maintain a medical
records system, which is consistent with professional standards, pursuant to
Section 456.057, F.S. The insurer or
delegated entity shall develop and implement policies and procedures that:
(a) Permit prompt retrieval of legible and
timely information, which is accurately documented and readily available if
requested by a health care practitioner with written authorization and consent
from the patient when required by statute;
(b) Protect the confidentiality and security
of paper and electronic patient records including:
1. Transfer, storage, and faxing of records;
and,
2. Handling of records
containing information on HIV, substance abuse, and mental health, in
accordance with statutory requirements;
(c) Provide for the training and education of
administrative staff and providers on medical record documentation, policies
and procedures, storage and confidentiality of patient records;
(d) Document in the medical record a summary,
related to work injury or illness, of significant procedures, past and current
diagnoses or problems and allergies and adverse reactions to current
medications;
(e) Identify the
patient as follows:
1. Name;
2. Social Security, alien identification
number, or other identification number;
3. Date of Birth; Employer; home and work
telephone numbers;
4. Sex; and,
5. Date of work injury or
illness.
(f) Indicate in
the medical record for each visit the following information:
1. Date;
2. Chief complaint, unresolved problems or
complaints from prior interventions and purpose of visit;
3. Objective findings of
practitioner;
4. Diagnosis or
medical impression;
5. Studies
ordered, for example: lab, x-ray, EKG, and referral reports;
6. Therapies administered and
prescribed;
7. Name and profession
of practitioner rendering services, for example: M.D., D.O., D.C., D.P.M.,
R.N., O.D., etc., including signature or initials of practitioner;
8. Disposition, recommendations,
instructions, and education to the patient. Evidence of whether there was
follow-up and the specific time of return is noted in weeks, months or as
needed;
9. Outcome of
services;
10. Work status, release
for return to work, work restrictions; and,
11. Evidence of coordination of care and any
injured employee non-compliance with treatment.
(g) Require the insurer or delegated entity
to request written consent of patients for release of medical records that are
subject to the limitations in Sections
381.004 and
456.057, F.S., and for obtaining
and sharing all documents and medical records from providers necessary to carry
out the provisions of Section
440.134, F.S.; and,
(h) Address transfer and retrieval of
records, and provision of copies when requested by the patient, designated
representative, or the Agency pursuant to Section
440.13(4)(c),
F.S. The insurer or delegated entity shall communicate its policy to providers
via provider educational materials.
(3) Case Files. The insurer or delegated
entity shall maintain electronic or paper medical information necessary to
ensure the efficient functioning of the care coordination process. The insurer
or delegated entity shall develop and implement a policy and procedure that
protects the confidentiality and security of case file information including
the transfer and storage of paper and electronic information, and the handling
of information on HIV, substance abuse, and mental health. Case files shall
contain necessary information for the coordination of quality patient care
between providers, insurers, employees, and employers including:
(a) The information from the notice of injury
required by Section 440.13(4)(a),
F.S.;
(b) The current primary care
physician, primary care physician changes and the designated medical care
coordinator;
(c) The treating
physician's plan of care;
(d)
Medical reports and information necessary to support the coordination of
medical care;
(e) The injured
employee's work status, work restrictions, date of maximum medical improvement,
and permanent impairment ratings; and,
(f) Efforts toward rehabilitation and
reemployment of the injured employee.
(4) Audits of provider records. The insurer
or delegated entity shall implement an ongoing process for conducting medical
record audits to determine compliance with the medical record standards
specified under paragraphs (2)(d), (e) and (f). The insurer or delegated entity
shall have a written methodology for determining the size and scope of the
medical record audits that shall reflect the volume and complexity of services
provided by the provider network. The insurer or delegated entity shall develop
and implement an annual work plan for the medical record audits. The results of
the audits shall be reported quarterly to the quality assurance committee and
shall include the following:
(a) Number of
physicians reviewed by county and by specialty;
(b) Areas where specific improvements in
record keeping are indicated;
(c)
Results from implementing improvements recommended in prior audits;
(d) Recommendations for education and
feedback to providers; and,
(e)
Extent to which the physician's treatment plan was
implemented.
Rulemaking Authority 440.134(25) FS. Law Implemented
440.134(5)(c), (6)(c)1.-4., 8., (7), (8)
FS.
New 9-12-94, Amended 10-8-01,
1-22-02.
