64B14-7.002. Patient Records

(1) Licensees and Registrants shall prepare and maintain in a timely manner patient records which include, at a minimum, the following:

(a) The patient name (on each page of the record), address and telephone number;

(b) The location and dates of all treatment, evaluation or consultation;

(c) The identity of each provider of treatment, evaluation or consultation and the supervisor, if any;

(d) The name of the prescribing physician;

(e) All prescriptions relevant to the patient;

(f) A treatment or service plan;

(g) Progress notes for each session must include the treatment provider’s name and signature, and date of occurance. In the event the treatment provider is a Resident or Intern as defined in subsection 64B14-7.001(5), F.A.C., the licensed supervisor shall countersign each progress note.

(h) Progress notes shall be typed or handwritten in black or blue ink and in such a manner that all material is clearly legible, including the treatment provider’s name and signature.

(2) The licensee may charge a fee for the reproduction of records, which shall be no greater than $1.00 per page for the first 25 pages, and $0.50 per page for every page after 25. In addition, the actual cost of postage may be added. Reasonable costs of reproducing radiographs and such other kinds of records shall be the actual costs. “Actual costs” means the cost of the material and supplies used to duplicate the record and the labor and overhead costs associated with the duplication.

(3) The licensee shall retain the patient record for at least seven years from the date of last entry, unless otherwise provided by law.

Rulemaking Authority 468.802 FS. Law Implemented 468.802 FS. History–New 7-1-98, Amended 6-22-09, 1-10-12.