Florida Administrative Code
64 - DEPARTMENT OF HEALTH
64B8 - Board of Medicine
Chapter 64B8-44 - STANDARDS OF PRACTICE
Section 64B8-44.004 - Documentation

(1) All licensees shall keep written patient records which shall include the nutrition assessment, the nutrition counseling plan, dietary orders, nutrition advice, patient progress notes, recommendations related to the patient's health or the patient's food or supplement intake, and any patient examination or test results.

(2) Prior to implementing a dietary or nutrition plan for a condition, the licensee must inquire whether the patient is under the active care of a licensed medical doctor, osteopathic physician, or chiropractic physician for that condition, and secure a written or oral dietary or nutrition order of the referring physician or the licensee must have been granted nutrition ordering privileges by the medical staff of a licensed care facility. If prior authorization is not practicable, the licensee may use professional discretion in providing nutrition services until authorization is obtained from the physician. The requirements of this subsection must be fully and completely documented in the patient's record.

(3) Upon recognition that a patient who is not already under the care of a medical doctor, osteopathic physician, or chiropractic physician has a condition which is treatable within the scope of practice of any of these three health care providers, the licensee must refer the patient to one or more of these providers. The requirements of this subsection must be fully and completely documented in the patient's record.

(4) The licensee shall sign and date all patient records.

(5) The licensee shall keep in confidence whatever he may learn about a patient in the discharge of professional duties and keep all patient records confidential. Information shall be divulged by the licensee when required by law, rule of the Board, or authorized by the patient.

(6) Inaccurate recording, falsifying or altering patient records including the nutrition assessment and documents required by this rule shall constitute a failure to maintain acceptable standards of practice.