61G18-18.002: Maintenance of Medical Records
PURPOSE AND EFFECT: To more clearly establish the appropriate amount of time within which medical records shall be created and to make more specific the content of said records.
SUMMARY: This proposed modification removes a less precise term of art with a more specific time frame as related to the creation of medical records subsequent to treatment or examination. Further, the proposal makes more clear the requisite content of said medical records.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:
The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the agency.
The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: During discussion of this rule at its Board meeting, the Board, based upon the expertise and experience of its members, determined that a Statement of Estimated Regulatory Cost (SERC) was not necessary. No person or interested party submitted additional information regarding the economic impact at that time. The Board has determined that this will not have an adverse impact on small business, or likely increase regulatory costs in excess of $200,000 in the aggregate within 1 year after implementation of the rule. These rule amendments will not require ratification by the Legislature.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
RULEMAKING AUTHORITY: 474.206, 474.216 FS.
LAW IMPLEMENTED: 474.216 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN THE FAW.
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Juanita Chastain, Executive Director, Board of Veterinary Medicine, Department of Business and Professional Regulation, 1940 North Monroe Street, Tallahassee, Florida 32399-0750
THE FULL TEXT OF THE PROPOSED RULE IS:
61G18-18.002 Maintenance of Medical Records.
(1) through (2) No change.
(3) Medical records shall be contemporaneously written as treatment is provided or within 24 hours from the time of treatment and include the date of each service performed. They shall contain the following information:
Name of owner or agent
Patient identification
Record of any vaccinations administered
Complaint or reason for provision of services
History
Physical examination to include, but not limited to patient weight, temperature, pulse, and respiration
Any present illness or injury noted
Provisional diagnosis or health status determination
(4) In addition, medical records shall contain the following information if these services are provided or occur during the examination or treatment of an animal or animals:
Clinical laboratory reports
Radiographs and their interpretation
Consultation
Treatment medical, surgical
Hospitalization
Drugs prescribed, administered, or dispensed along with the route, strength, and dosage of the drug and time said drug was administered,
Tissue examination report
Necropsy findings
(5) through (9) No change.
Rulemaking Authority 481.2055 FS. Law Implemented 481.221(4) FS. HistoryNew 1-16-86, Amended 5-16-89, Formerly 21B-18.002, Amended________.
