Current through Reg. 50, No. 187; September 24, 2024
(1) Each center
shall establish processes to obtain, manage, and utilize information to enhance
and improve individual and organizational performance in patient care,
management, and support processes. Such processes shall:
(a) Be planned and designed to meet the
center's internal and external information needs;
(b) Provide for confidentiality, integrity
and security;
(c) Provide education
and training in information management principles to decision-makers and other
center personnel who generate, collect, and analyze information; and,
(d) Provide for information in a timely and
accurate manner;
(2) Each
center shall have a medical records service, patient information system or
similarly titled unit with administrative responsibility for medical
records.
(3) The administrator
shall appoint in writing a qualified person responsible for the medical records
service. This person shall meet the qualifications established for this
position, in writing, by the governing board.
(4) A current job description delineating
duties and responsibilities shall be maintained for each medical records
service position.
(5) The medical
records service shall:
(a) Maintain a system
of identification and filing to ensure the prompt location of a patient's
medical record. Patient records may be stored on electronic medium such as
computer, microfilm or optical imaging;
(b) Maintain a current and complete medical
record for every patient admitted to the center.
(c) All clinical information pertaining to
the patient's medical treatment shall be centralized in the patient's medical
record.
(d) Ensure that each
medical record shall contain the following, as appropriate to the service
provided:
1. Identification data;
2. Chief complaint;
3. Present illness;
4. Past personal history;
5. Family medical history;
6. Physical examination report;
7. Provisional and pre-operative
diagnosis;
8. Clinical laboratory
reports;
9. Radiology, diagnostic
imaging, and ancillary testing reports;
10. Consultation reports;
11. Medical and surgical treatment notes and
reports;
12. The appropriate
informed consent signed by the patient;
13. Record of medication and dosage
administered;
14. Tissue
reports;
15. Physician
orders;
16. Physician and nurse
progress notes;
17. Final
diagnosis;
18. Discharge summary;
and,
19. Autopsy report, if
appropriate.
(e) Ensure
that:
1. Operative reports signed by the
surgeon shall be recorded in the patient's record immediately following surgery
or that an operative progress note is entered in the patient record to provide
pertinent information; and,
2.
Postoperative information shall include vital signs, level of consciousness,
medications, blood or blood components, complications and management of those
events, identification of direct providers of care, discharge information from
post-anesthesia care area.
(f) Index, and maintain on a current basis,
all medical records according to surgical procedure and
physician.
Rulemaking Authority 395.1055 FS. Law Implemented 395.1055,
395.3025 FS.
New 6-14-78, Formerly 10D-30.12, 10D-30.012, Amended
11-13-95, 9-17-14.
