59A-8.022. Clinical Records

(1) A clinical record must be maintained for each patient receiving nursing or therapy services that includes all the services provided directly by the employees of the home health agency and those provided by contracted individuals or agencies.

(2) No information may be disclosed from the patient’s file without the written consent of the patient or the patient’s guardian. All information received by any employee, contractor, or AHCA employee regarding a patient of the home health agency is confidential and exempt from Chapter 119, F.S.

(3) If the patient transfers to another home health agency, a copy of his record must be transferred at his request.

(4) All clinical records must be retained by the home health agency as required in Section 400.491, F.S. Retained records can be stored as hard paper copy, microfilm, computer disks or tapes and must be retrievable for use during unannounced surveys as required in Section 408.811, F.S.

(5) Clinical records must contain the following:

(a) Source of referral;

(b) Physician, physician assistant, or advanced registered nurse practitioner’s verbal orders initiated by the physician, physician assistant, or advanced registered nurse practitioner prior to start of care and signed by the physician, physician assistant, or advanced registered nurse practitioner as required in Section 400.487(2), F.S.

(c) Assessment of the patient’s needs;

(d) Statement of patient or caregiver problems;

(e) Statement of patient’s and caregiver’s ability to provide interim services;

(f) Identification sheet for the patient with name, address, telephone number, date of birth, sex, agency case number, caregiver, next of kin or guardian;

(g) Plan of care or service provision plan and all subsequent updates and changes;

(h) Clinical and service notes, signed and dated by the staff member providing the service which shall include:

1. Initial assessments and progress notes with changes in the person’s condition;

2. Services rendered;

3. Observations;

4. Instructions to the patient and caregiver or guardian, including administration of and adverse reactions to medications;

(i) Home visits to patients for supervision of staff providing services;

(j) Reports of case conferences;

(k) Reports to physicians, physician assistants, or advanced registered nurse practitioners;

(l) Termination summary including the date of first and last visit, the reason for termination of service, an evaluation of established goals at time of termination, the condition of the patient on discharge and the disposition of the patient.

(6) The following applies to signatures in the clinical record:

(a) Facsimile Signatures. The plan of care or written order may be transmitted by facsimile machine. The home health agency is not required to have the original signature on file. However, the home health agency is responsible for obtaining original signatures if an issue surfaces that would require certification of an original signature.

(b) Alternative Signatures. Home health agencies that maintain patient records by computer rather than hard copy may use electronic signatures. However, all such entries must be appropriately authenticated and dated. Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry. The home health agency must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records in the event of a system breakdown.

Rulemaking Authority 400.497 FS. Law Implemented 400.491, 400.494 FS. History–New 4-19-76, Amended 2-2-77, Formerly 10D-68.22, Amended 4-30-86, 8-10-88, Formerly 10D-68.022, Amended 10-27-94, 1-17-00, 7-18-01, 9-22-05, 8-15-06, 3-29-07, 7-11-13.