59A-18.012. Clinical Records

The licensed nurse responsible for the delivery of skilled patient care shall maintain a clinical record, pursuant to Section 400.497(8), F.S., for each patient receiving nursing services in the home that shall include, at a minimum, the following:

(1) Identification sheet containing the patient’s name, address, telephone number, date of birth, sex, and caregiver or guardian;

(2) Before information can be released, an authorization for such release must be dated and signed by the patient, caregiver, or guardian;

(3) Plan of treatment as required in Section 400.506(13), F.S.;

(4) Clinical and service notes, signed and dated by the nurse providing the service which shall include:

(a) Any assessments by a registered nurse;

(b) Progress notes with changes in the person’s condition;

(c) Services provided;

(d) Observations; and,

(e) Instructions to the patient and caregiver;

(5) Reports to physicians;

(6) Termination summary including:

(a) The date of the first and last visit;

(b) The reason for termination of services;

(c) An evaluation of established goals at time of termination;

(d) The condition of the patient at the time of termination of services; and,

(e) The referral for additional services when the patient requires continuing services.

(7) Each nurse registry shall keep clinical records received from the independent contractor licensed nurse for 5 years following the termination of service. Retained records can be stored as hard paper copy, microfilm, computer disks or tapes and must be retrievable for use during unannounced surveys.

(8) The nurse registry is not obligated to review patient or client records per Section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. In the event of violation of state law which comes to the attention of the nurse registry, the nurse registry shall take the actions specified in Section 400.506(19), F.S.

Rulemaking Authority 400.497, 400.506 FS. Law Implemented 400.497, 400.506 FS. History–New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 5-4-15.