Current through Reg. 50, No. 187; September 24, 2024
(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.
Rulemaking Authority
397.321(5) FS.
Law Implemented 397.321(3)(c),
397.4014,
397.410,
397.4103
FS.
New 8-29-19.
