64B15-15.004. Written Records; Minimum Content; Retention

(1) For the purpose of implementing the provisions of Section 459.015(1)(o), F.S., osteopathic physicians shall maintain written legible records on each patient in English, with sufficient detail to clearly demonstrate why the course of treatment was undertaken. The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately. Such written records shall contain, at a minimum, the following information about the patient:

(a) Patient histories;

(b) Examination results;

(c) Test results;

(d) Records of drugs prescribed, dispensed or administered;

(e) Reports of consultations;

(f) Reports of hospitalizations; and,

(g) 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.

(2) Medical records in which compounded medications are administered to a patient in an office setting must contain, at a minimum, the following information:

(a) The name and concentration of medication administered;

(b) The lot number of the medication administered;

(c) The expiration date of the medication administered;

(d) The name of the compounding pharmacy or manufacturer;

(e) The site of administration on the patient;

(f) The amount of medication administered; and,

(g) The date medication administered.

(3) All entries made into the medical records shall be accurately dated and timed. Late entries are permitted, but must be clearly and accurately noted as late entries and dated and timed accurately when they are entered into the record. However, office records do not need to be timed, just dated.

(4) Whenever patient records are released or transferred, the osteopathic physician releasing or transferring the records shall maintain either the original records or copies thereof and a notation shall be made in the retained records indicating to whom the records were released or transferred. However, whenever patient records are released or transferred directly to another Florida licensed physician, or licensed health care provider it is sufficient for the releasing or transferring osteopathic physician to maintain a listing of each patient whose records have been so released or transferred which listing also includes the physician or licensed health care provider to whom such records were released or transferred. Such listing shall be maintained for a period of five (5) years.

(5) In order that the patients may have meaningful access to their records pursuant to Section 456.058, F.S., an osteopathic physician shall maintain the written record of a patient for a period of at least five (5) years from the date the patient was last examined or treated by the osteopathic physician. However, upon the death of the osteopathic physician, the provisions of Rule 64B15-15.001, F.A.C., are controlling, and when an osteopathic physician terminates practice or relocates and is no longer available to patients, the provisions of Rule 64B15-15.002, F.A.C., are controlling.

Rulemaking Authority 456.058, 459.005 FS. Law Implemented 456.058, 459.015(1)(o) FS. History–New 11-30-94, Amended 10-25-95, Formerly 59W-15.004, Amended 12-22-97, 9-9-13, 3-8-18, 11-29-22.