59A-23.005. Medical Records and Case Files

(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. History–New 9-12-94, Amended 10-8-01, 1-22-02.