63M-2.061. Record Documentation, Development and Maintenance

(1) All Individual Health Care Records shall remain confidential.

(2) The Individual Health Care Record consists of two sections:

(a) Section 1: Core Health Profile, and

(b) Section 2: Interdisciplinary Health Record. The Interdisciplinary Health Record contains the additional subsections of the Individual Health Care Record that include the current Practitioners orders and Chronological Progress Notes, historical medical documentation, and treatment records and documents of ancillary care.

(3) A youth’s official case file shall include health care records along with the management file.

(4) All handwritten documentation in the Individual Health Care Record shall be recorded legibly in blue or black ink. No correction fluid or erasure will be used in the IHCR. Corrections shall be made by crossing through with a single line and the deleted section initialed.

(5) Health care documents shall be filed in a chronological organized manner.

(6) Each detention center shall be responsible for the initial development of a youth’s Individual Health Care Record when a youth is admitted to the facility, unless all of the following criteria are met:

(a) Has no known health problems, is receiving no prescribed medications and denies health problems during the Facility Entry Physical Health Screening; and

(b) Experiences no health care problems or concerns during the detention stay and receives no health-related screenings or evaluations other than the initial Facility Entry Physical Health Screening; and

(c) Is released from detention with no charges pending and/or is released on community control or other form of non-residential departmental supervision; and

(d) Has been in the custody of the detention center no longer than 3 days; and is not committed to the department for residential placement.

(7) When a youth is admitted to a residential commitment program and has not had an Individual Health Care Record initiated, the receiving residential commitment program shall be responsible for obtaining the Health-Related History (HRH) and Comprehensive Physical Assessment (CPA) from the Juvenile Probation Officer (JPO).

(8) The youth’s JPO is responsible for ensuring that the youth receives his/her HRH and CPA prior to placement in a residential program.

(9) All documents contained in the Individual Health Care Record shall become a permanent part of the youth’s record.

(10) Each facility shall maintain an Individual Health Care Record for each youth.

(11) The IHCR shall be maintained intact with the original documentation except:

(a) When off site providers retain the original notes in their files;

(b) When Medicaid is billed for services and requires the original records for billing;

(c) When the original form has otherwise been lost.

In these situations, original, clean, legible copies are acceptable and shall be retained in the record as if they were the originals. “COPY” shall be written or stamped on the document in an area that does not obscure any necessary information.

(12) The IHCR shall be transported with the youth between department facilities and shall be documented on the Custody of Health Care Record. The Custody of Health Care Record (HS 005, October 2006) is incorporated into this rule and is available electronically at http://www.flrules.org/Gateway/reference.asp?No=Ref-03824 or may be obtained by contacting: DJJ, Office of Health Services, 2737 Centerview Drive, Tallahassee, FL 32399.

Rulemaking Authority 985.64(2) FS. Law Implemented 985.64(2), 985.145, 985.18 FS. History–New 3-16-14.