64B2-17.0065. Minimal Recordkeeping Standards

(1) These standards apply to all licensed chiropractic physicians and certified chiropractic assistants. These standards also apply to those examinations advertised at a reduced fee, or free (no charge) service.

(2) Medical records are maintained for the following purposes:

(a) To serve as a basis for planning patient care and for continuity in the evaluation of the patient’s condition and treatment.

(b) To furnish documentary evidence of the course of the patient’s medical evaluation, treatment, and change in condition.

(c) To document communication between the practitioner responsible for the patient and any other health care professional who contributes to the patient’s care.

(d) To assist in protecting the legal interest of the patient, the hospital, and the practitioner responsible for the patient.

(3) The medical record shall be legibly maintained and shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately, by including, at a minimum, patient histories; examination results; test results; records of drugs dispensed or administered; reports of consultations and hospitalizations; and copies of records or reports or other documentation obtained from other health care practitioners at the request of the physician and relied upon by the physician in determining the appropriate treatment of the patient. Initial and follow-up services (daily records) shall consist of documentation to justify care. If abbreviations or symbols are used in the daily recordkeeping, a key must be provided.

(4) All patient records shall include:

(a) Patient history,

(b) Symptomatology and/or wellness care,

(c) Examination finding(s), including X-rays when medically or clinically indicated,

(d) Diagnosis,

(e) Prognosis,

(f) Assessment(s),

(g) Treatment plan, and

(h) Treatment(s) provided.

(5) All entries made into the medical records shall be accurately dated. The treating physician must be readily identifiable either by signature, initials, or printed name on the record. Late entries are permitted, but must be clearly and accurately noted as late entries and dated accurately when they are entered into the record.

(6) Once a treatment plan is established, daily records shall include:

(a) Subjective complaint(s)

(b) Objective finding(s)

(c) Assessment(s)

(d) Treatment(s) provided, and

(e) Periodic reassessments as indicated.

(7) In situations involving medical examinations, tests, procedures, or treatments requested by an employer, an insurance company, or another third party, appropriate medical records shall be maintained by the physician and shall be subject to Section 456.057, Florida Statutes. However, when such examinations, tests, procedures, or treatments are pursuant to a court order or rule or are conducted as part of an independent medical examination pursuant to Section 440.13 or 627.736(7), Florida Statutes, the record maintenance requirements of Section 456.057, Florida Statutes, and this rule do not apply. Nothing herein shall be interpreted to permit the destruction of medical records that have been made pursuant to any examination, test, procedure, or treatment except as permitted by law or rule.

(8) Provided the Board takes disciplinary action against a chiropractic physician for any reason, these minimal clinical standards will apply. It is understood that these procedures are the accepted standard(s) under this chapter.

Specific Authority 460.405 FS. Law Implemented 460.413(1)(m) FS. History–New 4-22-90, Formerly 21D-17.0065, 61F2-17.0065, Amended 10-1-95, 12-10-95, 3-13-96, Formerly 59N-17.0065, Amended 4-22-98.